23 Korean National Immunization Program For Children

2012 Modularization of Koreas Development Experience:
Korean National Immunization

Program for Children
2013
2012 Modularization of Koreas Development Experience:
Korean National Immunization Program

for Children
2012 Modularization of Koreas Development Experience
Korean National Immunization Program

for Children
Title
Korean National Immunization Program for Children
Supervised by
Ministry of Health and Welfare, Republic of Korea
Prepared by
C
hungnam National University
Author
Sok-Goo Lee, Chungnam National University School of

Medicine, Professor (Principal Investigator)
So-Youn Jeon, Daejeon Health Sciences College, Professor
Keon-Yeop Kim, Kyungpook National University School of
Medicine, Professor
Ho-Jin Nam, Chungnam National University School of
Medicine, Researcher
Jin-Kyung Lee, Chungnam National University School of
Medicine, Researcher
Advisory Hoan-Jong Lee, Seoul National University College of Medicine,

Professor
Research Management
K
DI School of Public Policy and Management
Supported by
Ministry of Strategy and Finance (MOSF), Republic of Korea
Government Publications Registration Number 11-7003625-000039-01

ISBN 979-11-5545-055-0 94320
ISBN 979-11-5545-032-1 [SET 42]
Copyright 2013 by Ministry of Strategy and Finance, Republic of Korea
Government Publications
Registration Number
11-7003625-000039-01
Knowledge Sharing Program
Korean National Immunization

Program for Children
Preface
The study of Koreas economic and social transformation offers a unique opportunity
to better understand the factors that drive development. Within one generation, Korea
has transformed itself from a poor agrarian society to a modern industrial nation, a feat
never seen before. What makes Koreas experience so unique is that its rapid economic
development was relatively broad-based, meaning that the fruits of Koreas rapid growth
were shared by many. The challenge of course is unlocking the secrets behind Koreas
rapid and broad-based development, which can offer invaluable insights and lessons and
knowledge that can be shared with the rest of the international community.
Recognizing this, the Korean Ministry of Strategy and Finance (MOSF) and the Korea
Development Institute (KDI) launched the Knowledge Sharing Program (KSP) in 2004
to share Koreas development experience and to assist its developing country partners.
The body of work presented in this volume is part of a greater initiative launched in 2010
to systematically research and document Koreas development experience and to deliver
standardized content as case studies. The goal of this undertaking is to offer a deeper
and wider understanding of Koreas development experience with the hope that Koreas
past can offer lessons for developing countries in search of sustainable and broad-based
development. This is a continuation of a multi-year undertaking to study and document
Koreas development experience, and it builds on the 40 case studies completed in 2011.
Here, we present 41 new studies that explore various development-oriented themes such
as industrialization, energy, human resource development, government administration,
Information and Communication Technology (ICT), agricultural development, land
development, and environment.
In presenting these new studies, I would like to take this opportunity to express my
gratitude to all those involved in this great undertaking. It was through their hard work
and commitment that made this possible. Foremost, I would like to thank the Ministry of
Strategy and Finance for their encouragement and full support of this project. I especially
would like to thank the KSP Executive Committee, composed of related ministries/
departments, and the various Korean research institutes, for their involvement and the
invaluable role they played in bringing this project together. I would also like to thank all
the former public officials and senior practitioners for lending their time, keen insights and
expertise in preparation of the case studies.
Indeed, the successful completion of the case studies was made possible by the dedication
of the researchers from the public sector and academia involved in conducting the studies,
which I believe will go a long way in advancing knowledge on not only Koreas own
development but also development in general. Lastly, I would like to express my gratitude
to Professor Joon-Kyung Kim and Professor Dong-Young Kim for his stewardship of this
enterprise, and to the Development Research Team for their hard work and dedication in
successfully managing and completing this project.
As always, the views and opinions expressed by the authors in the body of work presented
here do not necessary represent those of the KDI School of Public Policy and Management.
May 2013
Joohoon Kim
Acting President
KDI School of Public Policy and Management
Contents
| LIST OF CHAPTERS
Summary 19
Chapter 1
Background 21
1. History of Korean Immunization Program22
2. Institutional and Legal Transitions35
3. Changes in Organizations Dedicated to Immunization40
3.1. Before the Establishment of the Department (up to 2002)40
3.2. After the Establishment of the Department (from 2003)41
Chapter 2
National Immunization Program 43
1. Organizations Managing Immunizations44
2. Expert Committees48
2.1. Immunization Expert Committee48
2.2. Expert Committee on Compensation for Immunization Victims 49
3. Recommended Immunization Schedules50
06 Korean National Immunization Program for Children
Chapter 3
Immunization Service Providers 55
1. Public and Private Providers56
1.1. Public Sector56
1.2. Private Sector62
2. Reimbursement System62
2.1. Background62
2.2. Program Evolution64
2.3. Major Strategies65
2.4. Program Performance65
2.5. Program Implementation System66
2.6. Implications68
Chapter 4
Vaccine Supply Systems 69
1. Vaccine Production and Sales70
2. Vaccine Supply71
2.1. Public Procurement Service72
2.2. Wholesalers73
2.3. Manufacturers73
3. Vaccine Supply Monitoring System73
4. Implications74
Contents 07
Contents | LIST OF CHAPTERS
Chapter 5
Immunization Reporting Systems 77
1. Immunization Registry Information System78
1.1. Introduction78
1.2. Project Promotion Progress79
1.3. Project Promotion Strategies80
1.4. Project Promotion Accomplishments81
1.5. Project Promotion System81
1.6. Legal Reporting Responsibility84
1.7. Implications85
2. Immunization Certification for School Entry85
2.1. Introduction85
2.3. Implications88
3. Adverse Reaction Monitoring System88
3.1. Introduction88
3.2. Project Promotion Process89
3.5. Implications94
4. Infectious Disease Surveillance System94

4.1. Introduction94
4.5. Implications102
Chapter 6
Immunization Success Stories 103
1. Hepatitis B104
1.1. Background104
1.2. Program Progress Timeline106
1.3. Program Implementation Performance106
1.4. Program Implementation System108
2. Measles113
2.1. Background113
2.2. Program Timeline114
2.3. Program Implementation and Execution114
3. Pandemic Influenza A (H1N1)119
3.1. Background119
3.2. Program Implementation and System121
3.3. Program Implementation126
Contents 09
Contents | LIST OF CHAPTERS
Chapter 7
Strategies for Increasing Public Participation 129
1. Vaccination Week130
1.1. Background130
1.3. Suggestions132
2. Immunization Reference Website132
2.1. Background132
3. Short Message Service (SMS) for Confirmation of Immunization and Notification of Next
Immunization Schedules 133
3.1. Background133
4. Vaccination Training for Health Care Providers134
4.1. Background134
Chapter 8
Monitoring of Immunization Outcomes 139
1. Korean National Immunization Survey140
1.1. Introduction140
1.2. Introduction to the Survey 141
1.3. Survey Results143
2. Factors Affecting the Immunization Rate 146
2.1. Background146
2.2. Survey Introduction146
2.3. Survey Results147
Chapter 9
Directions for Future Development 153
References 157
Appendix 160
Contents 011
Contents | LIST OF TABLES
Chapter 1
Table 1-1 History of the Korean Immunization Program24
Table 1-2 Social Health Indicators in Korea 1960-198027
Table 1-3 The Percentages of Rural Areas with Medical Personnel 29
Table 1-4 Contents of Major Laws related to Immunizations and Types of National

Immunizations37
Chapter 2
Table 2-1 Tasks of the National Agencies related to Immunization45
Table 2-2 Ages and Intervals for National Standard Pediatric Immunizations50
Chapter 3
Table 3-1 Legal Systems to Secure Doctors for Underserved Areas60
Table 3-2 Performance of the Medical Institution Reimbursement System66
Chapter 4
Table 4-1 Manufacturing of Vaccines for National Required Immunizations of Infants in 2011

71
Chapter 5
Table 5-1 Results of the National Immunization Programs Computerized Registry81
Table 5-2 Types of Information Gathered in the Immunization Registry Information System82
Table 5-3 Management Status for the National Compensation Policy for Adverse Reactions93
Table 5-4 Incidence Rate Trends for Acute Infectious Diseases98
Table 5-5 Incidence of (Category II) Vaccine Preventable Diseases99
Table 5-6 Reporting Status of Incidences via Mandatory Surveillance of Nationally Notifiable

Communicable Diseases100
Table 5-7 Reports of Deaths due to Nationally Notifiable Communicable Diseases102
Chapter 6
Table 6-1 Status of the Program for Initial Registry of Infants with Perinatal Hepatitis B107
Table 6-2 Status of Medical Institutions Participating in Preventing Perinatal Hepatitis B

Infection107
Table 6-3 Survey Results of Elementary and Middle School Students116
Table 6-4 Priority Targets for the H1N1 Influenza Vaccine122
Table 6-5 Methods of Providing H1N1 Influenza Immunization Service according to the

Individuals Targeted by the Program123
Table 6-6 Major Features of the H1N1 Influenza Immunization Management System124
Contents 013
Contents | LIST OF TABLES
Chapter 7
Table 7-1 Number of Members Registered in the Immunization Reference Website132
Table 7-2 Number of Visits to the Immunization Reference Website133
Table 7-3 Online Training Courses for Medical Institutions in 2012135
Table 7-4 Special Offline Vaccination Training Courses for Health Care Providers136
Chapter 8
Table 8-1 Immunization Rates by Schedule for the Core Required Immunization List in 2011

(Three-year-old Children)144
Table 8-2 Completed NIP Immunization Rates in 2011 (Three-year-old Children)145
Table 8-3 Relationship between Parents Ages and Rates of Completed Immunization147
Table 8-4 Relationship between Parents Education Level and Rate of Completed

Immunizations148
Table 8-5 Relationship between Parents Employment and Rate of Completed Immunization

149
Table 8-6 Relationship between Health Care Security Status and Rate of Completed

Immunization149
Table 8-7 Relationship among the Total Number of Children, Birth Order, and Rate of Completed

Immunization150
Table 8-8 Relationship between Obstacles to Immunization and Complete Immunization Rates

151
Contents | LIST OF FIGURES
Chapter 1
Figure 1-1 Relationship between Annual Economic Level and Incidence of Infectious Diseases

per 100,000 People26
Figure 1-2 Family Planning and Immunization Classes (1960s)30
Figure 1-3 Group Immunizations Administered in a Rural Village (1960s)31
Figure 1-4 Cholera Immunizations Administered for Train Passengers at the Daegu Station

(1970s)32
Figure 1-5 Immunizations inside a Train Car32
Figure 1-6 The Historical Development of Immunization-related Organizations42
Chapter 2
Figure 2-1 Immunization-related Organizations in the Korea Centers for Disease Control and

Prevention46
Figure 2-2 Relationship of the General Administrative System and the Health Administrative

System47
Figure 2-3 National Standard Immunization Schedule for Children53
Chapter 3
Figure 3-1 Mass Immunizations at a School (1971)58
Figure 3-2 Reimbursement System for Medical Institutions67
Figure 3-3 Reimbursement System for Immunization Expenses67
Contents 015
Contents | LIST OF FIGURES
Chapter 4
Figure 4-1 Procedure for Domestic Vaccine Supply72
Figure 4-2 Screenshot of the Vaccine Monitoring System74
Chapter 5
Figure 5-1 Screenshot of the Portal System of the KCDCs Immunization Registry Information

System83
Figure 5-2 Screenshot of an Immunization Record Registry accessed through the Immunization

Registry Information System83
Figure 5-3 Screenshot of an Immunization Record Registry accessed through a Private Medical

Institutions Electronic Medical Recording System (EMR)84
Figure 5-4 Project System for Immunization Certification for School Entry87
Figure 5-5 National Safety Management System for Adverse Reactions91
Figure 5-6 Adverse Reaction Reporting System91
Figure 5-7 Reporting System for Nationally Notifiable Communicable Diseases96
Chapter 6
Figure 6-1 Important Programs for Managing Hepatitis B in Korea and Status of Reduction of

Individuals Who Tested Positive for Surface Antigen (Survey of Donors)105
Figure 6-2 Program to Prevent Perinatal Hepatitis B108
Figure 6-3 Procedures in the Program to Prevent Perinatal Hepatitis B Infection111
Figure 6-4 Flowchart of the Program to Prevent Perinatal Hepatitis B Infection112
Figure 6-5 Measles Incidences per Year (1963-2000)113
Figure 6-6 Status of Measles Immunization History by Age115
Figure 6-7 Staged Goals and Programs for Measles Eradication117
Figure 6-8 Relationship between Incidence of Measles and Measles Immunization Coverage

118
Figure 6-9 Progress and Policy Regarding 2009-2010 H1N1 Influenza120
Figure 6-10 Implementation of the H1N1Influenza Immunization Program121
Figure 6-11 Priorities for H1N1 Influenza Immunizations by Time Period123
Figure 6-12 Supply System for the H1N1 Influenza Vaccine125
Figure 6-13 Screenshot of the H1N1 Influenza Immunization Registry Information System126
Contents 017
Contents | LIST OF BOXES
Chapter 1
Box 1-1 Smallpox and Ji, SeokYeong23
Box 1-2 Example of Public Relations for Child Vaccination through the Newspaper33
Summary
In this report, the development of the immunization program in the Republic of (South)
Korea, hereafter Korea, is examined from the 1950s up to present. This report also
examined policies that were enacted to provide immunization services in a situation where
there was a low level of awareness and participation by the general public. It is also our
intention that this report can be used as a reference for countries that do not have sufficient
resources totreat communicablediseases orfor countries that have only recently introduced
immunization policies. In addition, by detailing the prevention of perinatal hepatitis B
transmission, the eradication of measles, and the experiences of fighting H1N1 influenza,
we also want to share Koreas experiences in coping effectively with new infectious
diseases as they are discovered. Every individuals life is precious. Therefore, ineffective
public health programs or policies should never be implemented, even when a country has
a low socio-economic status or the interest of the general public wanes. The latter half of
this report focused on major immunization policies in detail that have been introduced and
implemented in Korea in order to help ensure the development of quality immunization
programs.
The content of this report is, briefly, as follows: In Chapter 1, important changes and
problems in the development of Koreas immunization program from past to present
are described. In Chapter 2, current immunization organizations and committees are
introduced. Chapter 3 covers the types and characteristics of immunization providers
with a focus on the participation of private medical institutions through the immunization
reimbursement system. Chapter 4 focuses on the vaccine provider system and shows the
differences between the vaccine provider system in Korea and those of other countries.
Chapter 5 specifies the important strategy for eradicating infectious diseases by verifying
preschool childrens immunization status through a centralized Immunization Registry
Summary 019
Information System. Chapter 6 introduces Koreas internationally well-regarded hepatitis

B immunization program, which has maintained the prevalence rate of hepatitis B around
3% and has dramatically reduced perinatal hepatitis B transmission. This chapter also
covers the measles eradication program and the successful management of the frightening
H1N1 influenza epidemic. Chapter 7 explores the recent strategies employed to raise
citizen participation in the national immunization programs. In Chapter 8, Koreas unique
immunization coverage survey is covered in detail. Lastly, a list of government publications,
a summary of immunization programs, and immunization methods conducted by the
government are included in the Appendix.
We hope that this report will help immunization professionals, lead to more development
in immunization programs, and inspire a national effort to take on new challenges.

Chapter 1
Background
1. History of Korean Immunization Program

2. Institutional and Legal Transitions
3. Changes in Organizations Dedicated to Immunization
Background
1. History of Korean Immunization Program

Immunizations not only stop infectious diseases from spreading but also help infected
patients avoid sequelae. Immunizations also protect herd immunity by controlling the
propagation of infectious diseases. Therefore, in practice, a 100% vaccination rate is not
required.
The history of the Korean vaccination program began during the Joseon dynasty
with immunizations against smallpox. The program was mainly the result of efforts of
various scholars and traditional doctors. In 1882, Ji, SeokYeong founded the first institution
for smallpox immunizations by opening an immunization clinic in the Jeonju Fortress. Ji,
SeokYeong learned Japanese inoculation methods in Busan and introduced them to Korea.
Notably, the immunization regulations of 1895 and the local immunization regulations of
1898 set out a legal basis for the immunization program in Korea [Box 1-1].
Box 1-1 | Smallpox and Ji, SeokYeong

Ji was born on May 15th, 1855 to a noble yet financially strapped family. Studying
oriental medicine at early age, he was supported by his father. His father was quite
knowledgeable in medicine although his aristocratic lineage stopped him from running
a medical clinic. Very friendly with middle-class doctors of the time, Jis father sent
his smart and inquisitive son to study Chinese medicine under the respected physician
Park, Young Sun. But in the 19th century, western studies were just coming into the
country and Ji was soon introduced to western medicine.
Jis mentor, Park learned of the smallpox vaccination method from a Japanese
doctor when he visited Japan as part of the government delegation in 1876. He brought
back a book on smallpox inoculation and taught his students the new and effective
treatment for smallpox. The innovative treatment had helped Ji broaden the world of
medicine and offered him a way to eradicate one of the most fatal diseases.
But learning from a book has limitations, and Ji wanted more. He found out that
a Japanese naval clinic in Busan was administering smallpox shots to Japanese
residents. So he walked 20 days down to the port city to ask the clinic to teach him
about the vaccination. Impressed by Jis commitment and passion, the Japanese naval
doctor trained him for two months.
In 1879, Ji became the first Korean physician to vaccinate against smallpox, when
he administered his first smallpox shot to a two-year-old brother-in-law. It was a great
success, but the problem was the shortage of vaccines. He could not learn how to
manufacture the vaccine. So he traveled to Japan in 1880 with diplomatic envoys and
learned how to manufacture the smallpox vaccine. Upon his return to Joseon, he set
up a vaccine production base in Seoul and launched a nationwide vaccination program.
Source: h ttp://world.kbs.co.kr/english/program/program_koreanstory_detail.htm??lang=e&current_
page=9&No=25970
Until 1945, the management of infectious diseases was under the oversight of the
Japanese occupation forces. After the liberation in 1945 until the end of 1950 when the
Korean War ended, the UN Allied Forces were responsible for overseeing the war. Yet, due
to the situation, there was a sudden increase in patients with hepatitis, epidemic hemorrhagic
fever, typhus, smallpox, and diphtheria.The UN forces managed infectious disease through
group immunizations and quarantining infected patients. Their oversight extended not only
over the soldiers, but over the general population as well <Table 1-1>.
Chapter 1. Background 023
Table 1-1 | History of the Korean Immunization Program

Year
Diseases targeted
Important background information
1882 Smallpox
Establishment of clinic in the Jeonju

Fortress
1895 Smallpox
Enactment of inoculation regulations

(Ordinance for the Empire, section 8)
1945 Cholera
Production of vaccination and

implementation of an immunization
program (Joseon Epidemic Prevention
Institute)
1949
Diphtheria, tetanus, 8 other

diseases
1952 Tuberculosis
Smallpox, diphtheria, whooping
1954 cough, typhoid fever, typhus,

paratyphoid fever, tuberculosis
Production of vaccination and

program (Joseon Epidemic Prevention
Institute)
Production of BCG vaccination and
program
Epidemic prevention measures instituted
(designated as routine immunization)
1958 Polio
Inactivated vaccine used for immunization

of some populations
(Live diluted vaccine introduced in 61)
1965 Measles
Implementation of an immunization
program
1976 Cholera, tetanus
Routine immunizations introduced
1978 Smallpox
WHO declared eradication of smallpox

in 1979; suspension of smallpox
immunizations
1980 Measles, mumps, rubella (MMR)
MMR vaccine introduced
1983 Measles, polio
Introduction of routine immunizations
1990 Cholera
Suspension of vaccination
1995 Hepatitis B
Changed the 85 temporary immunization

to routine immunization
2000 Mumps, rubella
2001 Measles
Implementation of an ambitious 5 year

catch-up plan to eradicate measles
2004 Diphtheria, tetanus
Introduction of Td immunizations
2005 Varicella (Chicken pox)
Year
Diseases targeted
Important background information
2006 Measles
Measles declared eradicated; measles

vaccinations suspended
2008 Hepatitis B
WHO certified management of hepatitis B
2009 H1N1 Influenza
Private medical institutions began to

participate in the routine immunization
program
2011
Diphtheria, tetanus, pertussis,

polio
2012 Diphtheria, tetanus, pertussis
Introduction of DTaP-IPV immunization

Introduction of Tdap immunization
BCG: Mycobacterium bovis bacillus Calmette-Gurin; WHO: World Health Organization; MMR: measles,
mumps, and rubella; Td: tetanus, diphtheria; DTaP-IPV: diphtheria, tetanus, acellular pertussis and
inactivated poliomyelitis virus vaccine
Source: Administrative reports of Korea Centers for Disease Control and Prevention
The UN Allied Forces oversight of infectious diseases led to a marked reduction of

sudden epidemics. [Figure 1-1] shows that infectious diseases greatly increased after the
Korean War in the early 1950s. When the economic situation started to improve in the
1970s, there was a decrease in infectious diseases. It is clear from [Figure 1-1] that infectious
diseases could be managed through an aggressive emphasis on a hygienic environment and
a collective approach despite weak infrastructure. As a result, when the economic situation
improved and medical system was revamped, there was a sharp decrease in infectious
diseases. In other words, there is an inverse relationship between the annual rate of economic
development and the incidence of infectious diseases [Figure 1-1].
Figure 1-1 | Relationship between Annual Economic Level and Incidence

of Infectious Diseases per 100,000 People
Average Incidence Rate (per Population of 100,000)
14.00
Gross Domestic (GDP) (Units: 1,000,000,000 won)
1400000
12.00
1200000
10.00
1000000
8.00
800000
6.00
600000
4.00
400000
2.00
200000
0.00
0
1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011
Year
One of the problems in offering vaccination service during the mid-1950s was that
in 1951, due to the Korean War, foreign troops who were stationed in Korea conducted
group vaccinations that resulted in a temporary decrease of infectious diseases. However,
the demand of the general public could not be met because there were no regular
immunization services available for them. To solve these problems, immunization centers
were set up in every town, sub-county, and neighborhood so that immunizations could be
given regularly. The government also appointed one certified professional to each center
(Gyeonggi Province archives, 1953). Specifically, doctors, oriental medicine doctors,
dentists, pharmacists, nurses, and other experienced health professionals were chosen and
given short-term training by the local health director so they could be hired as staff in
locations where no medical staff had worked previously. In order to provide convenient
accessibility, certified professionals were also appointed to offer immunization services at
regional immunization clinics and other regional health institutions. The cost was borne
by state and local governments, and the immunizations were free. When an allowance was
designated for a specific, health center, health clinic, or medical institution, the medical
personnel who worked in locations, which lacked stationed doctors, were paid only. When
an epidemic occurred, these measures and basic medical resources acted as a very effective
means of improving the accessibility of immunization in neighborhoods where there
werent enough medical staff. However, because of its coercive nature, there was a lack of
active participation among medical institutions.
The government put considerable effort to appoint physicians to each town and subcounty.1 In the 1960s and 70s after the Korean War ended, one of the main concerns was
to prepare measures for areas where there were no doctors. The first policy attempted to
commission a practitioner in private practice as the community doctor and the director of the
community health clinic. From the 1960s to the 80s, the head of the county2 commissioned
certain physicians in private practice to be public doctors, including many geographically
restricted doctors.3 Effort was also made to alleviate the conditions in rural areas where there
were no doctors. This was done in two ways. One was a six-month specialized residency
training program that was implemented in health institutions in rural areas (in 1972). The
other was a program in 1976 to give medical licenses to medical students who had failed the
state medical examinations under the condition that they should work in a rural area where
there were no medical personnel for two years.
Table 1-2 | Social Health Indicators in Korea 1960-1980
Indicators
1960
1966
1970
1975
1980
Population growth rate

(per thousand)
3.01
2.57 (65)
2.21
1.70
1.57
Natural population growth

(per thousand)
30.0
25.1
23.2
17.1
15.4
Crude birth rate (per thousand)
42.1
34.6
31.2
24.8
22.6
Crude death rate (per thousand)
12.1
9.5
8.0
7.7
7.3
52.4
(M:51.1
F: 53.7)
M:54.92
F:60.99
61.93
(M:58.67
F:65.57)
63.82
(M:60.19
F:67.91)
65.69
(M:61.78
F:70.04)
58.2
46.2
53.0
38.0
17.3
8.3
5.6
4.2
Average lifespan (years)

Infant mortality rate
(per 1,000 births)
Maternal mortality rate
(per 100,000 births)
1. Town (eup) and sub-county (myeon): These two government administrative districts, towns and subcounties, are smaller divisions of counties (gun).
2. County (gun): This government administrative district encompasses multiple towns (eup) and subcounties (myeon), and generally denotes less densely populated areas than the city.
3. Geographically restricted doctor: Under the current medical law, physicians who were educated during
the Japanese colonial period (before 1945) or who were educated in North Korea hold a license that
restricts their medical practice to certain geographical areas.
Indicators
1960
1966
1970
1975
1980
79
125
255
607
1,660
Prevalence of tuberculosis
(per 100 people)
4.2
3.3
2.5
Cholera morbidity rate1)
0.6
0.4
0.2
0.4
Typhoid fever morbidity rate
11.2
11.8
13.1
1.5
0.5
Paratyphoid fever morbidity

rate1)
0.3
0.1
0.1
0.0
0.0
0.3
0.0
Epidemic typhus morbidity rate
0.1
0.0
0.0
Relapsing fever morbidity rate1)
3.3
4.4
1.8
1.0
0.1
Diphtheria morbidity rate1)
0.1
0.1
Epidemic meningitis morbidity

rate1)
5.0
Bacterial dysentery morbidity

rate1)
0.5
0.1
0.0
Polio morbidity rate1)
11.8
3.4
4.1
Pertussis morbidity rate1)
11.2
14.1
13.1
Measles morbidity rate
2.5
5.2
2.3
Mumps morbidity rate
49.4
0.9
0.1
0.1
0.1
0.0
0.0
0.1
Hemorrhagic fever morbidity

rate1)
5.0
12.2
0.1
0.3
0.3
Japanese B encephalitis
morbidity rate1)
5.0
12.2
0.1
0.3
0.3
Gross national income (GNI)

per capita (in dollars)
Dysentery morbidity rate
1)
1)
Smallpox morbidity rate1)

1)
1)
1)
Malaria morbidity rate
1)
Meningococcal meningitis
disease morbidity rate1)
*Data from each metropolitan city and provincial report.
1) rate=No. of incidence100,000/No. of average population
Source: 1. M
inistry of Health and Social Affairs (1961, 1962, 1974, 1979, 1981), Yearbook of Health and Social
Statistics, Ministry of Health and Social Affairs (in Korean)
2. National Bureau of Statistics of the Economic Planning Board (1966), Korea Statistical Yearbook,
Economic Planning Board (in Korean)
3. Korean Statistical Information Service (http://www.kosis.kr), Economic Statistics System of the Bank
of Korea (http://ecos.bok.or.kr/) (in Korean)
4. Park, NY (1970), Analysis of International Health Statistics and Data, Korea National Institute of
Health (in Korean)
In addition, in 1961, regulations pertaining to scholarships for health care personnel were
enacted (State Council Law, Section 249). Graduate students studying medicine and public
health could receive a scholarship if they worked in a specified area for 2-5 years after
graduation. In 1976, the Act on Special Cases for Health Care Scholarships was enacted,
which also provided scholarships for medical students. After graduation, the students were
appointed to a community health center and branch. Later, nursing students were included in
this program, and the government could recruit nurses in the same way. Similar ordinances
were enacted at the provincial and local levels. In this manner, a medical workforce was
secured. In 1980, the Act on Special Measures for Rural Health Care was enacted, and until
present, it has reliably supplied public health doctors4 (such as physicians, dentists, and
oriental medicine doctors) to health care centers and their branch offices. Likewise, a variety
of laws and institutional strategies were developed in order to address the rural areas and
areas where no doctors were stationed. As a result, after 1983, all areas now have doctors.
Due to such efforts, physicians working in health centers are providing preliminary checkups
and adequate health counseling for those who receive immunizations <Table 1-3>.
Table 1-3 | The Percentages of Rural Areas with Medical Personnel
(Unit: people, %)
Percentage
Percentage of the rural
of
population
population
with no
in rural
physician
areas
stationed in
their area
Percentage
of the rural
population
with no
dentist
stationed in
their area
Percentage
of the rural
population
with no
oriental
medical
doctor
stationed in
their area
Percentage
of rural
population
without any
medical
personnel
Year
Rural
population5
1952
16,070,667
81.2
48.3
70.1
53.6
35.3
1955
16,243,982
75.5
30.8
61.7
41.5
21.5
1960
17,995,264
72.0
29.5
61.8
43.1
18.5
1965
19,380,347
67.6
26.2
55.9
35.9
20.7
1970
18,507,899
58.8
20.2
48.3
33.9
16.7
1974
18,262,204
54.9
17.0
44.0
36.1
14.9
*Population ratio (%): Comparison of a percentage of the national population
Source: Ministry of Health and Social Affairs (1955-1957, 1964, 1974), Yearbook of Health and Social Statistics,
Ministry of Health and Social Affairs (in Korean), pp.9-12 in 1955-1957, pp.36-39in 1964, pp. 162-165 in 1974
4. Doctors, dentists, and oriental medicine doctors (public health doctors) were asked to carry out public
health work instead of military service.
5. More specifically, population of towns (eup) and sub-counties (myeon).
Apart from the doctors and dentists provided by the above strategies, the state gradually
started to deploy other health care personnel. At each health care center, three staffers were
deployed: one responsible for family planning, another responsible for maternal and child
infant health, and a third responsible for tuberculosis management. Immunizations were
included in child infant health.
In terms of immunization programs, only smallpox immunizations were offered without
charge before 1960. Afterwards this free program was extended to immunizations for
typhoid fever, cholera, DPT, TB, and others. However, despite high incidence rates and
death rates, there were cases that were not covered by the state like measles. For such
diseases, immunizations had to be administered at a private health institution and the
cost borne by the individual. Nevertheless, even in this inconvenient situation, the central
government set regional immunization goals. As family planning (such as birth control)
was advocated by World Health Organization advisers as a major challenge to address,
family planning personnel were placed in every town and sub-county. Along with these
family planning services, health education about immunizations and immunization services
were also offered. The benefits of immunizations were seen in rural areas [Figure 1-2]. In
addition, the efforts of international organizations played a major role in raising the general
publics awareness of health issues by emphasizing the importance of hygienic environment
such as kitchens, bathrooms, and clean wells. These all helped reducing infectious diseases.
Figure 1-2 | Family Planning and Immunization Classes (1960s)
Source: National Archives of Korea
During the months when infectious diseases spread (e.g., cholera and typhoid in
summer), immunizations were carried out at a large scale: at bus terminals, trains, markets,
and other places with a large transient population. This was a good opportunity to provide
immunizations to the general public. In particular, this strategy was important for providing
immunization access to those members of the public who were not proactive in visiting
a health care center. Immunizations for infectious respiratory diseases in children were
usually given by the family planning staff as they toured the village. Simultaneously, they
gave health instructions [Figure 1-3, 4, 5].
Figure 1-3 | Group Immunizations Administered in a Rural Village (1960s)
Figure 1-4 | Cholera Immunizations Administered for Train Passengers

at the Daegu Station (1970s)
Figure 1-5 | Immunizations inside a Train Car

It was very important to improve the residents awareness and knowledge of immunization
programs as well as immunization coverage through quantitative expansion and group
immunization programs. Emphasis on environmental sanitation to prevent infectious
diseases was very important given the low education level of the general public. Therefore,
there was particular interest at the national government level about instructions and public
awareness. Common instructions at that time were about sexually transmitted diseases,
tuberculosis, immunizations for infectious diseases, and food hygiene. Government
agencies developed educational materials, and such information was broadcast through a
variety of media including newspapers, leaflets, and broadcasts through street public address
systems. Due to the low level of formal education and the harsh economic environment, it
was difficult to access health care and immunizations. Furthermore, people barely knew
about the importance of immunizations. As a result, health education was very important
as it could reap significant benefits. When the socio-economic level of the nation began
to improve in the 1970s, the foundational education of the 60s provided an opportunity to
drastically improve the immunization program. There were also World Health Organization
advisors consisting of doctors, health officers, and a nursing supervisor at the health center
in Gongju, South Chungcheong Province (ChungcheongNamDo) who played an important
role in training health care workers and local residents about cleanliness, immunizations,
and family planning [Box 1-2].
Box 1-2 | Example of Public Relations for Child Vaccination
through the Newspaper
Source: h ttp://newslibrary.naver.com/viewer/view.nhn?editNo=2&printCount=&publishDate=1984-0202&officeId=00020&pageNo=11&printNo=19179&publishType=00020&articleId=&service-Start
Year=1920&serviceEndYear=1999
The public sector, specifically the community health centers active promotion of the
immunization program and the existence of maternal and infant health care centers, should
not be overlooked. Originally, workers identified pregnant women and registered them at the
community health center. This was part of their work related to maternal and infant care. Four
weeks after birth, the infant also was registered. Accordingly, their growth and development
were checked, and immunizations were given. From 1981 to 1984, additional maternal and
infant health care centers were built in approximately 91 places on county bases. This was
to serve residents of rural areas and to provide birth control, population growth control, and
health care for pregnant women and infants. When there were major installations, the cost was
borne by the foreign loan (International Bank for Reconstruction and Development; IBRD)
and the operating costs were borne by the national and county governments.
The public health center consisted of a convalescing room, delivery room, a newborn
nursery, and a day care center. The mayor and the head of the county took charge of the
center, provided strong administrative support, and appointed the health center director.
One out of three of the existing nursing staff was recruited from the rural maternal and
infant care centers to work in the city-or province-owned hospitals. The doctors were also
recruited to be public health physicians. Eventually, the maternal and infant health centers
were absorbed into the community health centers, and by the early 1990s, their functions
had gradually disappeared.
According to evaluation reports of the early days of the maternal and infant health care
centers, 0.2 people per day delivered infants, 3 infant per day were vaccinated, and 2 people
per day came for infant examinations and counseling (Ministry of the Interior, 1983). On
the whole, these operating results were much lower than those that were originally planned.
One reason for this was because of insufficient manpower and equipment to support infant
delivery. Lack of ability to cope with high risk deliveries and local residents preferences were
other reasons. During this time, the economy was rapidly developing and simultaneously,
private medical institutions were also developing. Hence, accessibility to private obstetrics
and gynecology institutions significantly improved, but this led to poor performance in the
public sector. Nonetheless, it is important that health care facilities for maternal and infant
health care were built in areas of poor conditions. In particular, when there was very little
political or social interest in health care, the Ministry of the Interiors directly managing the
program at the front lines was quite noteworthy. However, the maternal and infant health
centers failed to follow the rapid expansion of medical resources and could not fulfill their
intended goal. It is unfortunate that the maternal and infant health care centers were not
established earlier. It is also regretful that they did not have the resources to be quality
centers that could compete with the private sector. If they had, they might have had a greater
effect on the health environment in Korea.
2. Institutional and Legal Transitions

In Korea, the law for the prevention of infectious diseases was first enacted in 1954.
This law has been the foundation for the basic framework of the law on infectious disease
management in Korea. Revised in 2011, the most recent law is the Law on the Prevention
and Management of Infectious Diseases. The statute includes the following sections: Article
1, General Provisions (Types of Infectious Diseases); Article 2, Basic Planning and Program
(Appointment of a Secretary of Health and Welfare every five years); Article 3, Notification
and Reporting; Article 4, Monitoring and Epidemiological Investigation; Article 5, High
Risk Pathogens; Article 6, Immunizations; Article 7, Measures for Blocking the Propagation
of Infections; Article 8, Preventive Measures; Article 9, Epidemic Prevention, Quarantine
Commissioner and Epidemic Prevention Committee; and Article 10, Expenses.
The first law mentioned above was put in force from 1954 until 1999. Under this, it was
the responsibility of the guardian whose child was under 14 to have the child immunized.
Mental patients or those deemedincompetent were to be immunized following the same
policy.If the inoculations were not given, heavy fines were imposed. Through the heavy
fines, the government would attempt to increase the rate of inoculation coverage. From
1999, regulations forcing caregivers to access immunizations were abolished because
the immunization coverage rate goal had been reached. This was also because of the
increased awareness of human rights to preserve citizens freedom of choice. By granting
responsibility to the heads of the local governments for routine immunizations, a variety of
programs depending on local conditions could be developed and implemented to improve
immunization coverage.
The central and local government had to bear the burden of the cost specified by the
law. Thus, the expenses of the immunization program were clearly specified. The national
government was responsible for over 1/2 of the provincial share of the cost, and the
provincial government was responsible for 2/3 of the proportion that the county government
covered. Currently 50% of the cost is normally borne by the national government, 15%
(or 25%) borne by the provincial government, and 35% (or 25%) borne by the county
government <Table 1-4>.
Up to the present, from the legislative or organizational perspective, the immunization
program in Korea has been considered legally part of the prevention and management of
infectious diseases program, and there were no separate immunization laws. That is, the
overall legal basis for immunization has been considered in terms of the management of
infectious diseases by the Law on the Prevention and Management of Infectious Diseases.
So there was no law for immunization only. Consequently, unique and independent
immunization goals and strategies could not fully be performed.
Two types of immunization programs operate at the national level: the National
Required Immunization Program and the Complementary Immunization Program. Core
immunizations are based on professional review and the relevant national law. In case of a
sudden influx of an epidemic from overseas or a rapid increase of an infectious disease in
Korea, complementary immunizations are administered. As complementary immunizations
are meant to raise the immunity of a population to a certain disease in a short period of
time, the immunization programs are temporary. Prime examples are the immunizations
administered due to the rapid increase of measles in 2000 and the immunization because of
the swine influenza pandemic in 2010.
For a certain immunization to be included in the list of required immunizations, several
factors are taken into account. The most important factors are the incidence rate and
the fatality rate. When the law was first enacted, seven diseases -- smallpox, diphtheria,
pertussis, typhoid fever, typhus, paratyphoid, and tuberculosis -- were covered, but currently
eleven diseases-- hepatitis B, diphtheria, polio, pertussis, measles, tetanus, tuberculosis,
mumps, rubella, varicella, and Japanese encephalitis-- are targeted. Whether to include
hepatitis A, rotavirus, type b Haemophilus influenzae, and Streptococcus pneumoniais is
under consideration. In other words, there is continuous effort to include any disease that
significantly affects the population in the required immunization list.
The public health centers set up by local governments for required immunizations had
limitations that made it inconvenient for the public to use their immunization services.
However, after 2009, a change in the law allowed people to get required immunizations at
private medical institutions that were appointed. This was a plan to improve the quality and
quantity of immunization coverage that stemmed from the governments strong commitment
to fight against preventable infectious diseases. Currently, in 2012, immunizations in public
health centers are completely free. In addition to the immunizations offered by the state,
one can also receive immunizations at a private health institution, but in this case, the cost
must be borne by the individual, which is up to 5,000 won (approximately US $5.00) per
inoculation.
Table 1-4 | Contents of Major Laws related to Immunizations

and Types of National Immunizations
Guardians duties
and regulations
Year
regarding
required
immunizations
Types of required
immunizations
Obligation
of guardian
whose child
is 14 years
& under to
have the child
immunized
Obligation
of citizens
to receive
immunizations
Person
responsible
for the
immunizations:
leader of
municipality,
mayor
Types of
immunization(7):
smallpox,
diphtheria,
whooping
cough, typhoid
fever, typhus,
paratyphoid,
tuberculosis
Same
Person
responsible for
immunizations:
Leader of
municipality,
mayor, county
magistrate
Types of
immunization
(7): smallpox,
diphtheria,
whooping
cough, typhoid
fever, cholera,
tetanus, TB
(excluding typhus,
paratyphoid)
1954
1976
Burden of cost
National
Over half
of the
provincial
share
Same
Provincial
2/3 of
county
costs
Same
County
Temporary
immunizations
Remaining
cost except
national
and
provincial
subsidies
Ministers,
mayors, leader
of municipality
Same
Minister,
leader of
municipality,
mayor, county
magistrate
Guardians duties
and regulations
Year
regarding
required
immunizations
Burden of cost
Types of required
immunizations
National
Provincial
County
Temporary
immunizations
Same
Same
Same
Same
Same
Person
responsible for
immunizations:
Same
Types of
immunization
(6): diphtheria,
pertussis, tetanus,
tuberculosis,
polio, measles
(excluding
smallpox, typhoid,
cholera)
1995
Same
Person
responsible for
immunizations:
mayor, county
magistrate, ward
(district) head
Types of
immunization(7):
added hepatitis B
Same
Same
Same
Minister,
mayor, county
magistrate,
ward head
1999
Delete
provisions
pertaining to
immunization
obligations
Person
responsible for
immunizations:
Same
Types of
immunization (7):
Same
Same
Same
Same
Same
Same
Person
responsible for
immunizations:
Same
Types of
immunization (9):
mumps, rubella
added
Same
Same
Same
Same
1983
2000
Guardians duties
and regulations
Year
regarding
required
immunizations
2005
2006
2009
Burden of cost
Types of required
immunizations
National
Provincial
County
Temporary
immunizations
Same
Person
responsible for
immunizations:
Same
Types of
immunization
(10): varicella
added
Same
Same
Same
Same
Same
Person
responsible for
immunizations:
Same
Place of national
immunization:
Public health
center (can
commit to
private medical
institution)
Types of
immunization
(10): Same
Same
Same
Same
Same
Same
Person
responsible for
immunizations:
Same
Place of national
immunization:
Same
Types of
immunization
(11): Japanese
encephalitis
added
Same
Same
Same
Same
3. Changes in Organizations Dedicated to Immunization

3.1. Before the Establishment of the Department (up to 2002)
Child immunization was traditionally performed as part of maternal and infant care,
and the separate organization overseeing immunizations was eliminated from the central
and local governments. Even in the 1960s and 70s when various infectious diseases were
rampant, there was no separate system for child immunizations. What is worse, due to the
low level of hygiene, waterborne diseases spread rapidly during the summer. Furthermore,
only cholera and typhoid were immunized as these diseases led to death.
In 1948, after the Republic of Korea was founded, experts from the World Health
Organization were sent to improve Koreas low level of hygiene and to tackle the high birth
rate. In the field of environmental sanitation, the conventional kitchen and bathroom built
with clay was improved, and the improvement of wells was also a key focus. With respect
to the high birth rate, there was a focus on dispelling widely held preferences for boys and
providing contraception. These kinds of health education campaigns, along with the success
of economic development started in 1962, and the improvement in the level of education
among the general public contributed to the success even more in improving the sanitation
level.
In the same way, immunizations were offered as part of family planning or maternal and
infant health care. Due to health education on immunization services and the prevention
of infectious diseases, the general publics level of awareness gradually increased. This
was also a time of rapid socioeconomic development. Another notable point of this period
was that immunizations for children were considered to be part of maternal and infant
care, while immunizations for adults were considered to be projects for the prevention of
waterborne diseases (part of the Ministry of Health and Social Affairs quarantine division).
In other words, the immunization programs did not exist separately, but were considered to
be part of other programs. Consequently, there was only quantitative development and no
qualitative development of the immunization programs.
In 1999, the Division of Quarantine, the organization dedicated to fighting infectious
diseases, which had belonged to the Ministry of Health and Social Affairs (currently
the Ministry of Health and Welfare) was transferred to the National Institutes of Health
(currently the Korea Centers for Disease Control and Prevention). Gradually, there was
emphasis on expertise and technology in the management of a growing epidemic rather
than administrative solutions. In 2000, the sudden outbreak of measles created another
opportunity for a gradual change in the governments recognition of immunization. The
government began to recognize the limitations of existing quantitative supply-driven
immunization programs. Accordingly, interests in immunizations increased, and a variety

of research and programs began.
3.2. After the Establishment of the Department (from 2003)

In 2002, the Ministry of Health and Welfare was reorganized again. In the reorganization,
the childrens immunization program, which had been part of maternal and infant healthcare,
was transferred to the National Institutes of Health. As a result, the task of immunizing
children of the Ministry of Health and Welfare was merged with the task of adult
immunizations administered by the National Institutes of Health, Quarantine Division. This
unification at the level of the central government had an impact on the regional community
health centers, and consequently, a unified immunization system began to take form (but, at
the present time this change has been very limited to only a few health centers).
In 2003, the Korea Centers for Disease Control and Prevention was established, as an
expansion of the duties previously covered by the National Institutes of Health. In addition,
Koreas first separate immunization organization, the Immunization Management Division
(currently Division of Vaccine Preventable Disease Control and National Immunization
Program) was set up. After the department was formed, there were efforts to assemble
various professionals related to immunizations and immunizations, which had been seen
as part of the management of infectious diseases, was seen as a separate and independent
task. To improve the quality of the immunization program, a variety of efforts were
employed. A vision and goals for the immunization program were established, an individual
immunization records management system was put in place (the National Immunization
Registry Information System), and systematic training of the workforce in public health
centers and private medical institutions began. Private medical institutions started to
participate actively in the National Immunization Program in order to improve the qualified
immunization coverage rate, and the reminder/recall service was introduced. Furthermore,
the administration of immunizations for disadvantaged groups, the measurement of national
immunization coverage, and other such various policies were also revived.
Among all these policies, the introduction of the National Immunization Registry
Information System (IRIS) in 2002 was a significant landmark in Korean public health
history. In 2002 the basis of Korean immunization policy changed from quantity management
through group immunizations to quality management through personalized immunizations.
The development of various immunization-related institutions can be summarized as
follows: in 1945, the Joseon Epidemic Prevention Institute, which was responsible for
the prevention and control of infectious diseases, immunizations, production of vaccines,
research, etc., was established. In 1963, the National Institutes of Health, responsible
for the management of infectious diseases, research, and the education of health care
professionals, was established. Smallpox was declared to be eradicated in 1979, And the
National Institutes of Health assigned physicians in the cities and provinces to be trained as
epidemiology investigators in 1999. In the first decade of the 21st century, Korea celebrated
its rapid progress of its immunization programs. Polio was declared eradicated in Korea in
2000, and in the following year, the National Immunization Registry Information System
was established. In 2004, the Korean National Institutes of Health was reorganized and
the Korea Centers for Disease Control and Prevention was founded. In 2006, Measles
was declared eradicated in Korea and two years later, Korea received a certification for
maintaining those positive for hepatitis B surface antigen below 0.2% of the population
aged 15 or under [Figure 1-6].
Figure 1-6 | The Historical Development of Immunization-related Organizations
SARS pandemics 2002

Smallpox eradication
& EPI 1980
1879
smallpox
vaccination
1945
National quarantine
laboratory
1956
DTP vaccination
1983
HBV Vaccination
1963
1954
NIH establishment
Surveillance of legal
communicable disease
1999
Epidemic investigator
2009
2006
Domestic flu
Measles eradication
vaccine production
2004
CDC establishment
2008
WPRO HBV management certification
2002
IR
2000
Polio eradication
& IT communi. Dis. Surveil.
Start measles eradication plan (2001-2006)

Chapter 2
National Immunization Program
1. Organizations Managing Immunizations

2. Expert Committees
3. Recommended Immunization Schedules
National Immunization Program
1. Organizations Managing Immunizations

Koreas immunization-related organizations can generally be divided into the central
government level, the provincial and metropolitan city government level, and finally the
city, county, and district government level. At the central government level, there is the
Ministry of Health and Welfare and the Korea Centers for Disease Control and Prevention.
Other related organizations are the Food and Drug Administration that covers the testing
of imported and domestic vaccines in the country and the Public Procurement Service that
is responsible for purchasing and supplying vaccines used in community health centers.
The Department of Disease Policy under the Ministry of Health and Welfare, which is the
central organization, is responsible for drawing up and coordinating policies on infectious
diseases and illnesses. For setting up prevention plans and managing immunizations
targeting infectious diseases, the Division of Vaccine Preventable Disease (VPD) Control
and the National Immunization Program (NIP) of the Korea Centers for Disease Control
are in charge. Furthermore, they monitor adverse effects, operate the national compensation
scheme, supply the vaccines, and manage information. In terms of the development and
operation of concrete and practical strategies for the immunization program, various
professional committees are in authority <Table 2-1>.
Table 2-1 | Tasks of the National Agencies related to Immunization

Department in
charge
Major immunization-related tasks
Department of
Health and Welfare
(Disease Policies
Division)
Put all the policies on infectious diseases together and

coordinate them
Particulars regarding laws concerning infectious diseases
Particulars relating to measures preventing infections in
medical institutions
Support the National Tuberculosis Hospital and National
Hospital for Hansens Disease
Support the Korea Centers for Disease Control and Prevention
Support organizations and partnerships regarding tuberculosis,
Hansens disease, AIDS, and other infectious diseases
Korea Centers for

Disease Control and
Prevention
(VPD Control & NIP
Division)
Target infectious diseases, immunizations, and manage and

operate plans
Monitor adverse reactions after immunizations and
epidemiological investigations
Manage vaccination damage, national compensation surveys
Vaccination: standards of conduct and management methods
Coordinate and plan the supply and demand of vaccines,
support vaccine development
Carry out tasks regarding the registry of immunizations
Oversee the Immunization Expert Committee and the
Immunization Victims Compensation Committee
Educate and train diseases through public relations
Food and Drug

Administration
Manufacture, import and grant permission to imported items

and manufacture biological diagnostic medicine and biological
products
Assess the effectiveness, safety and quality of biological
diagnostic medicine and biological products
Assess the clinical examination plan for biological diagnostic
medicine and biological products
Preliminary review of biological diagnostic medicine and
biological products
Manage and set the standard for biological products
Public Procurement
Service
(Materials and
Equipment Division)
Analyze and evaluate purchases

Conduct surveys of procurement costs and particulars of the
system associated with expected pricing
Assess and adjust domestic supply and demand plans
Chapter 2. National Immunization Program 045
After its launch in 2003, all tasks are addressed under the Korea Centers for Disease
Control and Prevention. In terms of work content and quality, the program started to
gradually take on a professional image. In particular, the Ministry of Health and Welfare
Diseases Policy Division largely sets the immunization policy and the Korea Centers for
Disease Control VPD Control and NIP Divisions are in charge of technical judgments about
immunizations and the actual operation of immunization programs [Figure 2-1].
Figure 2-1 | Immunization-related Organizations in the Korea Centers
for Disease Control and Prevention
Korea Centers for Disease Control and

Prevention
Organ Transplant
Management Center
Epidemic Response
Center
Disease Prevention
Center
Department for the

Management of
Infectious Diseases
AIDS Managment
Department
Polio Virus
Department
Department for
Immunizations
Influenza Virus
Department
Department for the

Surveilance of
Infectious Diseases
Department for
Public
Crisis Response
Korea National
Institutes of Health
National Quarantine
Department
Respiratory Virus
Department
Division of
Bacterial
Raspiratory
Infactions
Department for
Zoonotic Diseases
As for local organizations, the provincial government fiscally supports the city, county,
and district health centers so that they can offer an immunization program. In particular, the
provincial government has the responsibility to check and report the performance of county
governments immunization programs to the national government. The county governments
set up public health centers and operate the facilities and personnel. For implementing the
immunization program, the public health center is in charge. A public health center offering
immunizations has the responsibility to oversee the practice of immunizations in the medical
institutions in the area under its jurisdiction. It also directly offers immunization services.
However, as community health centers are providing immunizations for free, it is difficult
for a public health center to work with private health institutions in offering immunizations.
Yet, even at private medical institutions, an individual can report adverse reactions after an
immunization. Guidance and supervision managing the quality of the immunizations are
also held at private medical institutions.
Under the public health center, there are public health center branches and health posts.
Normally the public health center branch employs one public health doctor, one dentist,
and two health staffers. Towns (eup) and sub-counties (myeon) under the jurisdiction of
each health facility carry out immunizations under the health centers guidance. For a
small or spread out population whose accessibility to the medical institution is difficult, a
health clinic (health post) is established in villages. One health staffer who holds a nurses
certificate works there and carries out immunizations for the citizens of that hamlet (ri)
under the health centers guidance [Figure 2-2].
Figure 2-2 | Relationship of the General Administrative System and the Health
Administrative System
Ministry of Public
Administration and
Security
(Central Government)
Organization and
operating budget
Ministry of Health and

Welfare
Public health program budget

and health policy support
Centers for Disease Control

and Prevention
Prevention
and
(Department of Health and
Human Services agencies)
Technology support and

project monitoring
City hall
(Metropolitian government)
Organization and
operating budget
County government
(Regional government)
Public health program budget

and technology support
Organization
and
operating
budget
Health center
Town (eup),
subcounty (myeon),
and neighborhood
block (tong)
Health center branch
Hamlet (ban, ri)
Health clinic(Post)
General administrative
system
Health administrative
system
Public health technology

support system
2. Expert Committees
Immunizations at the national level are under the jurisdiction of the Infectious Disease
Management Committee. This committee deliberates methods and standards of conducting
immunizations, and the pre-purchase, production, and stockpiling of medicine and
equipment.
Specifically, members of the committees include the Infectious Disease Management
Committee, the Immunization Expert Committee, the Expert Committee on Compensation
for Immunization Victims, the AIDS Committee, the Tuberculosis Committee, the
Committee for Epidemiological Investigations, and the Committee for Zoonotic Infections.
Of these committees, only two that are directly related to immunization will be introduced
below.
2.1. Immunization Expert Committee

Immunization Expert Committee is the most important committee with respect to
immunizations. It deals with the designation of diseases that should be targeted through
immunizations, immunization criteria and methods, policies on tackling infectious diseases
with immunizations, and the control (or eradication) of diseases.
The Immunization Expert Committee is composed of approximately 15 people. The
committee includes vaccine safety management personnel, immunization management
personnel, health care professionals, a person from civic groups, preventive medicine or
public health scholars, experts in the field of immunology, experts in the field of microbiology,
experts in the field of adverse reactions to immunizations, and experts in the field of health
economics. In addition, under the Immunization Expert Committee, there were twelve
subcommittees. Specifically, these are as follows: 1. Tuberculosis subcommittee, 2. Hepatitis
type A/B subcommittee, 3. Diphtheria-tetanus-pertusis (DTaP) polio subcommittee, 4.
Measles-mumps-rubella (MMR) subcommittee, 5. Japanese B encephalitis/hydrophobia
subcommittee, 6. Influenza subcommittee, 7. Varicella subcommittee, 8. Hemorrhagic
fever/typhoid subcommittee, 9. Haemophilus influenzae Type B (Hib)/pneumococcal/
meningococcal subcommittee, 10. Human papilloma virus subcommittee, 11. Rotavirus
subcommittee, 12. Adult subcommittee, and 13. Policy coordination subcommittee.
The role of the subcommittees is to research field-related important issues and develop
guidelines or advice. Each subcommittee is composed of less than 20 members. Also, there
is a commission for the eradication of infectious diseases and eradication certification (the
National Certification Commission on Measles and the National Certification Commission
of Polio Eradication) with approximately 10 members. This certification committee
performs surveillance and conducts research on infectious diseases. Afterwards, they assess
the alleviation and eradication of the diseases. They also write an annual report, submit the
report, plan the control and eradication of infectious diseases, and coordinate international
cooperation.
2.2. E
xpert Committee on Compensation for Immunization
Victims
The Expert Committee on Compensation for Immunization Victims holds hearings on
injuries or other related situations that arise from immunization. Some of the important
points deliberated upon include 1. whether the damage was caused by immunization
and what the requisite compensation is, 2. the standards and methods of compensation
for damages caused by immunization, 3. the particulars of additional condolence money
the head of the Infectious Disease Management Committee offers, and 4. whether there
was something wrong with the medicine used or a mistake made by the medical personnel
giving the immunization, and if so if it was willful or unintentional negligence by the person
administering the medicine used in immunizations or treatment or if it was by a third party.
The Expert Committee on Compensation for Immunization Victims has one chair, one
vice-chair, and 15 members. The members are 1. the managing director responsible for
vaccine safety in the Food and Drug Administration, 2. the managing director responsible
for immunizations in the Korea Centers for Disease Control and Prevention, 3. related
professionals (A. a clinical doctor with extensive experience in performing immunizations,
(Department of Pediatrics, Internal Medicine, etc.), B. a professional recommended by
immunization-related civic organizations, C. a lawyer recommended by the Korean bar
association, D. forensic scientists, E. medicine experts, F. experts in the field of diseases
targeted by immunizations, G. experts in the field of immunology associated with
immunizations, H. experts in the field of microbiology associated with immunizations, and
I. either members of the board of infectious disease management and related societies and
organizations or those who have received recommendations from committee members.
These professionals receive their appointment and commission from the chair of the
Infectious Disease Management Committee.
In addition, the Expert Committee on Compensation for Immunization Victims forms the
damage investigation team. Primary tasks are to determine whether death or other severe
adverse reactions occurred after the immunization, to perform initial epidemiological
investigations, and to decide whether to use the vaccine according to the provisional
conclusions and deliberations about the results of the autopsy and the epidemiological
investigations. The damage investigation team is composed of pediatrics specialists,
forensic experts, medicine experts, and, if required, immunization safety administrators
from the Food and Drug Administration.
3. Recommended Immunization Schedules

The standard immunization schedule (CDC, 2011) is based on the comprehensive
opinion of the specialized committees and sub-committees. Below is a detailed table of
national immunizations for children the types, the frequency, the intervals, and the ages
<Table 2-2>, [Figure 2-3].
Under the question, Which should be vaccinated? the benefit of the immunization, the
disease, and the dangers are reviewed before a decision is made. Furthermore, the decision
is influenced by the incidence rate, the severity, the cost and benefit, the general publics
acceptance, and a variety of other factors. Therefore, this is a continual process.
In Korea at present, there are 11 required immunizations that are offered. The World
Health Organization (WHO) recommends including Haemophilus influenzae type b (Hib),
Streptococcus pneumonia, hepatitis A, and rotavirus also, but immunizations for those
diseases are not included yet.
Table 2-2 | Ages and Intervals for National Standard Pediatric Immunizations
Disease
Vaccination
Recommended
time for the
immunization
Tuberculosis
BCG
(intradermal)
from birth to 1
month
Hepatitis B
(1st)
at birth
at birth
1 - 4 months
4 weeks
Hepatitis B
(2nd)
1 - 2 months
after birth
4 weeks
2 - 17 months
after birth
8 weeks
Hepatitis B
(3rd)
6 - 18 months
after birth
24 weeks
after birth
DTaP (1st)
2 months after
birth
6 weeks
after birth
2 months
4 weeks
DTaP (2nd)
4 months after
birth
10 weeks
after birth
2 months
4 weeks
DTaP (3rd)
6 months after
birth
14 weeks
6 - 12 months
after birth
6 months
DTaP (4th)
15 - 18 months
after birth
12 months
after birth
3 years
6 months
DTaP (5th)
4-6 years
4 years
Hepatitis B
Diphtheria
Tetanus
Pertussis
Next
Minimum
Minimum
immunization immunization
age
interval
interval
Disease
Polio
Measles
Mumps
Rubella
Japanese
encephalitis
Vaccination
Recommended
time for the
immunization
Next
Minimum
Minimum
age
interval
interval
Inactivated
vaccine
(IPV, 1st)
2 months after
birth
6 weeks
after birth
Inactivated
vaccine
(IPV, 2nd)
4 months after
birth
10 weeks
2 - 14 months
after birth
4 weeks
Inactivated
vaccine
(IPV, 3rd)
6 - 18 months
after birth
14 weeks
after birth
3 - 5 years
6 months
Inactivated
vaccine
(IPV, 4th)
4-6 years
4 years
MMR (1st)
12 - 15 months
after birth
12 months
after birth
3 - 5 years
4 weeks
MMR (2nd)
4 - 6 years
13 months
after birth
Inactivated
vaccine (1st)
12 - 23 months
12 months
7 - 30 days
7 days
Inactivated
vaccine (2nd)
12 - 23 months
12 months
12 months
6 months
Inactivated
vaccine (3rd)
24 - 35 months
18 months
3 - 4 years
2 years
Inactivated
vaccine (4th)
6 years
5 years
6 years
5 years
Inactivated
vaccine (5th)
12 years
11 years
Live
attenuated
vaccine (1st)
12 - 23 months
12 months
12 months
12 months
Live
attenuated
vaccine (2nd)
24 - 35 months
24 months
3 - 4 years
2 years
2 months
4 weeks
Disease
Influenza
Vaccination
Recommended
time for the
immunization
Inactivated
vaccine
at least 6
months after
birth
Live
attenuated
vaccine
Next
Minimum
Minimum
age
interval
interval
6 months
1 month
4 weeks
at least 24
months after
24 months
birth - 49 years
of age
1 month
4 weeks
12 months
after birth
4 weeks
4 weeks
Varicella
(Chicken
pox)
Varicella
12 - 15 months
after birth
Adult
diphtheria
and tetanus
Td
11 - 12 years
7 years
10 years
5 years
Adult
diphtheria,
tetanus, and
pertussis
Tdap
at least 11 years
11 years
1. The third dose of hepatitis B vaccine should be at least 8 weeks after the second dose and 16 weeks after the first
dose. The third dose should also not be prior to 24 weeks of age
2. The recommended interval between the third and fourth doses of DTaP is at least 6 months. However, if the
fourth dose was administered at least 4 months after the third dose, there is no need to administer the fourth
dose again
3. If there is a measles outbreak, infants between 6 and 12 months of age can be immunized. However, providing
measles immunizations for those under 12 months of age is not part of the standard immunization schedule
4. For children of 6 months to 9 years of age who have had only one dose or none, two doses of inactivated influenza
vaccine are recommended at a 4 week interval. Children in the same age range who have been immunized for
influenza can simply be vaccinated once a year
5. For children of 12 months to 13 years of age, one dose of varicella vaccine is enough. For those above age 13,
two doses are recommended at an interval of 4 weeks or more
Figure 2-3 | National Standard Immunization Schedule for Children
Source: Epidemiology & management of vaccine preventable disease

Chapter 3
Immunization Service Providers
1. Public and Private Providers

2. Reimbursement System
Immunization Service Providers
1. Public and Private Providers

1.1. Public Sector
Public health centers are established as a basic administrative structure in every city (si),
county (gun), and district (gu), which are the larger or more urban administrative districts
of Korea. Public health center branches affiliated with a public health center are established
in every town (eup) and sub-county (myeon), which are the administrative districts of more
rural areas. Health posts are established in a specific vulnerable hamlet (ri), which is the
smallest administrative unit in rural areas.
1.1.1. Public Health Centers

The healthcare administrative system was established in Korea in 1945 after liberation
from Japan. The next few years comprised of a politically turbulent period, which was only
after the Korean War (1951 - 1953) that the system gradually began to be improved. In
1956, a law to establish public health centers (currently the Community Health Act) was
first enacted. At first, public health centers were only established at the metropolitan and
provincial levels. It was not until 1963 that public health centers were established as frontline administrative units focused mainly on the city, county, and district level.
The public health centers have, up until now, been the facilities that offer the most
immunization services and are the organizations directly responsible for the national
immunization program. Although initially, the quantity of medical personnel was insufficient
for these public health centers, doctors, nurses, nurse assistants, and those with experience
working in medical institutions were put through a short period of training and were then
able to work as immunization staffers. Normally, the doctor is to determine whether it is

possible to inoculate and to note if there are symptoms or any physical problems. The actual
immunizations are given by the immunization staff. Currently, immunizations are usually
given by a public health staffer who holds a nurses certificate. Preliminary checkups are
always done by a physician. Although it differs depending on the location, in general, the
public health centers immunization workforce consists of a diagnostic doctor and two
nurses.
Even though private medical institutions have been extensively developed, the general
public considers the public health centers immunizations to be trustworthy, and because
of the low cost they are widely accessed. The required national immunizations are free
at public health care centers. For other immunizations in some public health centers, the
individual should pay for the cost of the vaccine only. Until 2008, the required national
immunizations were offered for free at the public health facilities, and this encouraged
the general public to visit public health centers for immunizations. On the other hand,
at private medical institutions, the individual had to cover all the expenses. From 2009
onwards, immunizations were offered at private medical institutions, but even the costs
of those on the list of national required immunizations were only partially covered by the
government. Beginning in 2012, the cost for the individual was only 10,000 won (about
US $10.00) and some qualify for a co-payment of less than 5,000 won (about US $5.00)
per inoculation. Consequently, the general public could receive immunizations at private
medical institutions at a minimal cost.
In the past, the greatest concern was herd immunity in Korea, so the strategy for this was
mass immunizations. Rather than the general public visiting a public health facility and
receiving personal immunizations, health care staffers traversed the villages and schools
and administered mass immunizations to those at each school or village on a week-by-week
basis [Figure 3-1]. In a situation where the economic level was so low that even medical
treatment could not be properly accessed, it was rare for citizens to go all the way to a
public health facility or medical facility to receive immunizations on their own initiative.
Consequently, health care staffers visited places where people lived, congregated people,
and implemented mass immunizations. This made a significant quantitative contribution to
immunization coverage.
Chapter 3. Immunization Service Providers 057
Figure 3-1 | Mass Immunizations at a School (1971)
As required immunizations were offered for free at the public health center, it was the
most important institution for immunizations for children despite the development of
transportation, the increase in privately owned vehicles, the increase in private medical
institutions, and the improvement in the quality of life. However, in addition to the 254
public health centers, 7,000 other medical institutions now offer immunizations with the
cost directly or indirectly covered. Of all of the immunizations offered, around 30% are now
offered at public health centers.
1.1.2. Public Health Center Branches

Public health center branches have been established not in cities but in the smaller
administrative districts of towns (eup) and sub-counties (myeon), which tend to be in less
densely populated areas. They were introduced in 1960 to solve problems of areas without
medical personnel. A public health center branch employs one doctor and three health care
staffers. One of the health care staffers is responsible for maternal and infant health care,
another for tuberculosis management, and the other for family planning. However, in many
branches of certain areas, it has been difficult to recruit doctors or public health staff.
Beginning around 1964 when the health center branches were first established, the
health care staff was selected by region and appointed to a public health center branch.
Because insufficient management of these branches was a problem, they were put under
the management of the town and sub-county heads in the end of the 1960s. These workers
were not full-time regular civil servants but were recruited as temporary contract workers.
Beginning around 1980, many of the public health care staffers lacked the required
qualifications for full-time work. Consequently, a qualifying exam was scheduled for
staffers, which was to be taken after training at the National Institutes of Health. If they
passed the exam, they could become full-time workers. In addition, in 1993 these staffers
of public health center branches were under the direct management of the public health
center director from a town or sub-county. The family planning tasks and the immunization
tasks were performed concurrently, which greatly contributed to solving the problem of
accessibility to immunization services in rural districts. Currently, there is one doctor and
one or two public health staffers at every health care branch.
As previously explained in the first chapter, in addition to public health staffers,
much effort had been put in up to this time to appoint doctors to those locations. One
way to induce doctors to serve at a public health center branch was a system of part-time
community doctors (commissioned doctors).6 In neighborhoods where there was no parttime community doctor, a practitioner in private practice in that area was commissioned as
the health center branch director as well as the branch doctor. Similarly, physicians were
recruited to public health center branches by a number of incentives, namely a residence
at or near the public health center branch, a (fixed) monthly salary approximately the
same as that of a general public official at a public health center, income derived from
patient care at the health branch was retained by the doctor as personal income, and other
incentives such the attainment of social status in the town or sub-county.
The health center branchs temporary doctor was under the management of the public
health center director, but health personnel as civil servants in that neighborhood were
under the administration of the head of the town or sub-county. In this redundant system,
the health personnel received health and medically related technology supervision from the
branch director (doctor). In the 1990s, the personnel management was consolidated into the
6. If the Health Branch Office of a rural area was not able to recruit a doctor to serve its community, a
doctor practicing in a nearby urban area was forced to serve at the Health Branch Office (mobilization
by Article 21 of the National Medical Act [1951]). In the 1970s, a doctor who was not able to pass the
national medical examination could be licensed to practice after working provisionally for two years in
a rural area.
public health center, and in the 1980s, doctors could fulfill their national military service
requirement by working as doctors in areas without doctors. This policy played the greatest
role in helping to eradicate the problem of lack of doctors in rural areas <Table 3-1>.
Table 3-1 | Legal Systems to Secure Doctors for Underserved Areas
Role
Year
implemented
Duration
of
doctors
service
Public health
physician
Act on special
measures for
rural healthcare
(Section 3335
Amended ,
80.12.31)
Doctors and dentists who

did not complete their
military service and were
incorporated in the reserve
officer corps. After working
in an area designated
by the Minister of Social
and Health Affairs, they
could be exempt from the
military service duty.
1979
3 years
Public health
scholarship
physicians
Act on special
cases concerning
public health
scholarships
(Section 2911
Amended
76.12.22)
Medical students who

received scholarships from
the government would
have their loans paid
depending on the number
of years engaged in public
health work.
1977
2-5
years
Specialized
duty assigned
physician
Medical law
article 11,
regulations
pertaining
to a doctors
conditional
license (Section
519 Amended
76.4.24)
Physicians who failed

the national medical
examinations could work
in a public health center
of particular rural region
for two years, and then be
licensed.
1976
2 years
In the case when there

was no doctor directing
a public health center or
branch, a private medical
practitioner was appointed.
1962
No limits
Division
Statutory basis
Appointed
(General and
Medical law,
geographically
article 57
restricted
doctors)
Source: M
inistry of Health and Social Affairs (1983), White Paper on Health and Society, Ministry of Health
and Social Affairs (in Korean), p.153
At this time, immunization health workers went out to administer immunizations at

a school, at a village hall, or in a vacant lot and regularly performed mass vaccinations.
It was the guardians responsibility to care for children under 14 for whom they were
responsible. Since infectious diseases were common, the general publics reaction towards
immunizations was very positive. Moreover, the magistrate of a county or heads of a town
or sub-county had responsibility for public health administration. Consequently, both the
administrative support and the business management for immunization were simpler.
The medicines used in the vaccines were supplied by the public health center, and
a regular refrigerator was installed in each health center branch to store the medicines.
However, if a large quantity of medicines was in need or if the electric power situation was
not optimal, the medicines were supplied directly from the public health center. During mass
immunizations, the medicines could be put in an icebox and moved conveniently. At this
time, the populace in rural areas did not have a proactive attitude towards immunizations
and did not usually come to a public health center branch for immunizations.
Recently there has been a reduced role for the public health center branches in
administering immunizations. The young population has left rural districts for the cities, and
there has consequently been a marked reduction in the population who would be targeted by
immunizations. With the increase in private medical institutions and the increase in private
car ownership, the use of city-based health care has also increased. The immunizations at
the public health center were administered after a preliminary checkup by a doctor (the
public health physician) and then the immunizations were given by the health staffers. The
national required immunizations were completely free. For all other immunizations, the
only cost was the price of the vaccine.
1.1.3. Health Posts

Health posts were established in hamlets as frontline health agencies. Regions that were
targeted for health posts had a resident population of more than 500 and were located where
it took over 30 minutes by public transportation from a medical institution. In September
1981, health posts were established firstly in 257 villages. Currently, there are 1,909 of
them. Health posts were proposed in the late 1970s as a strategy to solve a developing
countrys health problems. The reason for health post establishment was that in the majority
of rural districts, access to private medical institutions was very difficult.
In health posts, there is only one health staffer. The health staffers living space and the
clinic (treatment center) are sometimes in one building and sometimes in separate buildings.
Health staffers need a nurses license and should acquire a public health practitioners
qualification after receiving six months of training. Their main tasks include maternal and
infant care, family planning, treatment for minor illnesses, and chronic disease management.
However, with a drastic decrease in the young population, there are almost no young
people left who need immunizations. Hence, the significance or supply of immunizations
are not as much, compared to those of the past. Regardless, immunizations are still available
at health posts, and the national routine immunization can be obtained at no cost.
1.2. Private Sector

In the 60s and 70s, there were an insufficient number of private medical institutions.
Given the lack of service providers for those suffering from acute diseases, there was no
reason to exert particular effort regarding immunization services in private institutions.
Therefore, private medical institutions took only a small role in immunization service.
However, they are now growing in numbers.
Currently, it is estimated that approximately 7,000 private medical institutions offer

immunizations. Traditionally, the quantity of immunizations offered at private institutions
was small compared to those offered at public health centers (Until 2009, the immunizations
at private institutions accounted for 40% of the national immunizations for children).
Normally, one doctor, one nurse (or nurses assistant) and other health care staffers work at
each primary health care medical facility. Until 2000, immunization service was not covered
in the national health insurance, and national resources did not provide immunization
facilities at private medical institutions. Therefore, individuals who received immunizations
had to bear the whole immunization cost themselves.
In the past, only public health centers provided national routine immunizations. However,
private medical institutions argued that this was unfair and refused to cooperate with the
national immunization program. Accordingly from 2009, the system was improved so that
private medical institutions could be permitted to participate in the national immunization
program. As a result, the use of private medical institutions for immunizations is expected
to gradually rise.
2. Reimbursement System
2.1. Background
Starting in March 2009, a reimbursement system for private medical institutions was
introduced in national routine immunization. In this state-supported program, the state
bears the cost of mandatory immunizations for private institutions. This was an important
feature that distinguished it from previous immunization programs in Korea. In the 50s
and 60s, the poor socioeconomic level and specifically the low level of sanitation, caused
large scale epidemics and deaths. The lack of health care personnel and their low level of
training made the situation even more difficult. Therefore, the immunization policy at that
time was focused on giving immunizations to as much of the general public as possible.
Instead preparing in advance, immunizations were given at places such as train stations or
bus terminals during the spread of an epidemic. Under such circumstances, the formation
of a more robust policy for the purpose of improving the quality of the immunizations and
controlling/eradicating infectious diseases was remote.
As the general publics education level and their socio-economic level gradually
increased, the supply of medical staff became sufficient. Due to this improvement, the
overall quality of the immunization systems started to gain more focus. This focus brought
about the reimbursement system (a state-supported project to bear the costs of mandatory
immunizations). The programs goal was to improve the coverage of immunizations
until a disease had been successfully eradicated and to reduce and ultimately eradicate
infectious diseases that could be prevented. To further this goal, the main focus was to raise
immunization coverage to over 95% by enhancing the quality of immunization services,
improving the accessibility of immunization facilities for community citizens, and reducing
the cost burden of immunizations for guardians. At the societal level, the goal of this
program was to alleviate the burden of child care and decrease the health bills and medical
expenses of the general public through the reduction of infectious diseases.
For effective immunizations, the patient must be inoculated at a proper time and
in an appropriate manner, and have as many booster shots as required. In Korea, basic
immunization coverage is over 95%, but additional immunization coverage is only 90-94%.
In 2008, 59.5% of children from 0 to 6 years of age had full coverage (all immunizations,
namely 1BCG, 3HepB, 4DTaP, 3polio, and 1 MMR) (Pack, et al., 2009). In 2011, only
56.3% of children at age 3 had full immunization coverage (all immunizations, namely
1BCG, 3HepB, 4DTaP, 3polio, 1MMR, 1varicella, 3 (or 2) JEV) (Lee, et al., 2011).
In addition, approximately 7,000 medical facilities offered immunizations nationwide;
however, free immunizations were only given at the 254 public health centers. So those
who needed immunizations could get free immunizations only by going to the public health
center. Private medical institutions were easily accessible, but as the full cost had to be
borne by the individual (Ko, 2007; 50 (8): 600-601), the cost of the immunization was a
substantial burden. In the case of immunizations at a private medical institution, the cost of
the national required immunizations was approximately 490,000 won (450 US$) per infant.
This was an extra burden in childcare. Therefore, the purpose of the reimbursement system
(the National Immunization Reimbursement System) was to facilitate access to the national
required immunizations at the nearest medical institution through state support.
With the reimbursement system, the cost-benefit ratio of immunizations was approximately
4 to 30 times (for hepatitis B, 4 times; for polio, 9 times; for MMR, 24 times; and for DTaP,
32 times) (CDC, 2001). Therefore, this also greatly contributed to limiting national health
expenditures. The launch of the reimbursement system in Koreas immunization program
was a very important starting point. The change of focus from public health care center
immunization programs to the participation of private medical institutions was highly
significant. Particularly when immunizations at public health centers were free and those in
private medical institutions were not, there was a struggle between the private and public
sectors. However, after this was solved, private medical institutions could actively involve in
the national immunization program.
2.2. Program Evolution

2006: Basic legislation enacted (Participation of private medical institutions in the
national immunization program)
2009: Implementation of the medical facility reimbursement program (National program
for reimbursing the cost of required immunizations)
Contents supported: The cost of required immunizations at hospitals and clinics for
children ages 0 - 12
Vaccines supported: h epatitis B, tuberculosis (BCG, intradermal), diphtheria/tetanus/
pertussis (DTaP), polio (IPV), measles, mumps, rubella (MMR),
Japanese encephalitis (inactivated vaccine), varicella, tetanus/
diphtheria (Td) (8 types)
Costs supported: 3 0% of the immunization; an individual had to pay approximately
15,000 to 16,000 won (US $15.00-16.00).
2012: Expansion of the private medical facility reimbursement system (national program
to reimburse the cost of required immunizations)
Contents supported: The cost of required immunizations at hospitals or clinics for
children ages 0 - 12
Vaccines supported: B
CG (intradermal), hepatitis B, diphtheria/tetanus/pertussis (DTaP),
polio (IPV), varicella, measles/mumps/rubella (MMR), Japanese
encephalitis (inactivated vaccine), tetanus/diphtheria (Td), diphtheria/
tetanus/pertussis/polio (DTaP-IPV), tetanus/diphtheria/pertussis
(Tdap) (a total of 11 types of diseases, 10 types of vaccines)
Costs supported: 1 0,000 won (about US $10.00) cost of the vaccine and cost of the
inoculation (individual is responsible for less than 5,000 won about
US $5.00)
2.3. Major Strategies

2.3.1. State-supported National Essential Immunizations
Expansion of national support to cover the cost for national essential immunizations at
private medical institutions for children aged 12 and under
Expansion of the range of medical institutions giving immunizations (improvement of
accessibility for providers)
2.3.2. Improvement of Immunization Coverage in the Community

Immunization information guidance services (immunization schedules and missing
immunizations)
Management of immunizations for disadvantaged groups
Public relations regarding immunizations
2.3.3. Improvement in the Quality of Immunization Services

Immunization education for medical personnel
Stabilization of vaccine supply
Strengthening of the vaccine safety management system
Operation of the immunization registry
2.4. Program Performance

In 2011, the number of medical institutions participating in the reimbursement system
was 6,769 and the average number of applications for reimbursement per month was
272,486 <Table 3-2>. In June 2012, the number of medical institutions participating in the
medical institution reimbursement system (the national program for reimbursing the cost of
essential immunizations) was 7,149. The average number of applications for reimbursement
per month was 548,850.
Table 3-2 | Performance of the Medical Institution Reimbursement System

2009
2010
2011
Growth relative to
previous year (%)
Number of participating medical

institutions
3,949
4,937
6,769
5.6
Number of participating pediatric

clinics
364
1,011
2,302
1.9
87,666
119,648
272,486
101.4
Category
Average number of claims for

reimbursement per month
2.5. Program Implementation System

The mayor, county magistrate, and sub-county head (or public health center director)
have entrusted immunization services to the private medical institutions under their
jurisdictions. The medical institutions use the computerized Immunization Registry
Information System (IRIS) to type in individual immunization records. If an immunization
is registered, a claim for immunization reimbursement is automatically sent. When giving
the immunization, the medical institution should check the prior immunization record from
the immunization management information system before administering an immunization
so that the appropriate immunization could be administered [Figure 3-2].
Once the immunization is registered in the computerized Immunization Registry
Information System at the medical institution, the public health center will reimburse the
cost if it is covered by the reimbursement system [Figure 3-3].
Figure 3-2 | Reimbursement System for Medical Institutions
Korean Medical
Association
Korean Hospital
Association
Korean Medical
Practitioners
Association
Pubilic Care Center

Individual target management
and public relations at local level
Concentrated management for
vulnerable populations
Education and management for
medical institutions within
jurisdiction
Management of reimbursement
Project infrastructure
Program goals and strategies
Public relations
Im
Ap mu
pli niz
ca ati
tio on
Re
n
im
for reg
bu
re istra
rse
im tio
me
bu n
nt
rse
of
me
co
nt
sts
Immunization
cost review
committee
Korea Centers for Disease

Control and Prevention at
the Ministry of Health and
Welfare
Educational institution for immunization

(immunization On or offline)
Provides Immunizations
immunizations Schedule notification
Medical institution
Completion of immunization education
Immunization implementation and schedule notification
Registration of immunization records and application
for reimbursement
Provides immunizations
Community targets for

immunizations
Immunizations
Schedule notification
Figure 3-3 | Reimbursement System for Immunization Expenses
Medical
institutions
Public health
center
Application for
reimbursements of
expenses
Receipt
Audit
Reimbursement
decision
Cost payment
Recognition of
exceptions
Request for
professional
audit commission
Acceptance of
reimbursement
Denial of
reimbursement
Denial of
reimbursement
Appeals
(Protest of Formal
objection)
2.6. Implications
The socioeconomic level and the level of education of the general public have improved,
whereas the birth rate has decreased. Consequently, parents interest in their children has
been markedly increasing, and the rate of immunization coverage has also dramatically
increased. Correspondingly, there is continuous demand for a more sophisticated policy
with regard to the quality of scheduled and complementary immunizations. Furthermore, as
a result of the measles epidemic in 2000 and the H1N1 influenza epidemic in 2009, there is
a national consensus that the state should have a more sophisticated immunization program.
To solve some basic problems with quality of immunization, the government established
a computerized Immunization Registry Information System in 2002. The purpose of this
program was to promote the participation of private medical institutions in the National
Immunization Program and to increase access to institutions that offered children
immunizations. Through this initiative, free national immunizations that were available
only at the public health centers were expanded to private medical institutions. As a result,
not only at public health centers but also at private medical institutions, information of
personal immunizations could be saved in the Immunization Registry Information System.
Thanks to this system, immunization registries could be checked before immunizations
were given, the correct immunizations could be administered, and guardians could check
their childrens registry at any time.
Through such measures, the focus was changed from group vaccinations to individual
vaccinations. As the medical personnel could check the immunization status of every
individual, they could administer the required immunizations in a timely manner. This
boosted the effort to eradicate infectious diseases.

Chapter 4
Vaccine Supply Systems
1. Vaccine Production and Sales

2. Vaccine Supply
3. Vaccine Supply Monitoring System
4. Implications
Vaccine Supply Systems
1. Vaccine Production and Sales

Vaccines are different from general medicine because the uses of vaccines are very
limited and few. As a result, the proportion of vaccines in the whole market is small. Hence,
as the production and distribution of vaccines is difficult and costly, the state of the national
vaccine supply is worth consideration. Due to low product prices, profit margins are low.
Furthermore, the vaccine market has a small number of providers because existing vaccine
producers are in a dominant position in the market, multinational vaccine companies cause
market distortion, and the potential for market expansion is limited. This is markedly
different from other sectors of the pharmaceutical market. For these reasons, experts
recommend various policies to improve the market. That is, to supply vaccines more stably
and to further develop technologies.
In 2011, 14 companies in Korea were involved in the production and supply of vaccines,
including 7 domestic firms, 5 multinational firms, and 2 importers. The domestic companies
are normally involved in domestic manufacturing with either domestic or imported raw
materials. On the other hand, most multinational companies and importers are involved in
importing finished products.
In 2011, among the 30 immunization vaccines that are in circulation for the national
immunization of infants, only 8 (26.7%) were domestically manufactured, 16 (53.3%)
were imported as finished products, and 6 (20%) were manufactured domestically using
imported raw materials. Examining the manufacture of vaccines by type shows that 100%
of BCG, MMR, DTaP-IPV, and Tdap vaccines were finished imports. Hepatitis B and
Japanese encephalitis vaccines were 100% domestically manufactured, while DTap, polio,
and Td vaccines were either manufactured domestically with imported raw materials or
were imported as finished products. Varicella vaccines were either produced at domestic
production facilities or supplied through imports of the finished products <Table 4-1>.
Domestic firms produced their own vaccines for hepatitis B, Japanese encephalitis, and
varicella. BCG is scheduled to be produced domestically in the near future. DTaP, MMR,
polio, and other important vaccines were either produced overseas and then imported or
needed imported raw materials for production. Thus, shortages in domestic vaccine supply
could occur depending on changes in the international environment.
Table 4-1 | Manufacturing of Vaccines for National Required Immunizations
of Infants in 2011
(Unit: dose)
Type of
vaccine
Domestically
manufactured
Domestically
manufactured
with imported
raw materials
Imported finished
products
Total
BCG (blood
content)
0 (0.0%)
0 (0.0%)
37,110 (100.0%)
37,110 (100.0%)
0 (0.0%)
0 (0.0%)
3,997,903 (100.0%)
Hepatitis B 3,997,903 (100.0%)

DTaP
0 (0.0%)
2,287,459 (92.9%)
175,890 (7.1%)
2,463,349 (100.0%)
DTaP-IPV
0 (0.0%)
0 (0.0%)
331,864 (100.0%)
331,864 (100.0%)
Td
0 (0.0%)
220,973 (41.3%)
314,582 (58.7%)
535,555 (100.0%)
Tdap
0 (0.0%)
0 (0.0%)
150,691 (100.0%)
150,691 (100.0%)
Polio
0 (0.0%)
578,189 (38.0%)
942,522 (62.0%)
1,520,711 (100.0%)
MMR
0 (0.0%)
0 (0.0%)
Japanese
encephalitis
1,631,616 (100.0%)
(inactivated
vaccine)
Varicella
1,619,933 (86.6%)
1,204,710 (100.0%) 1,204,710 (100.0%)
0 (0.0%)
0 (0.0%)
1,631,616 (100.0%)
0 (0.0%)
250,140 (13.4%)
1,870,073 (100.0%)
Source: National Institute of Food and Drug Safety Evaluation
2. Vaccine Supply
The immunization providers in Korea are classified into the public health centers (those
functioning in the public sector) and medical institutions (functioning in the private sector).
Thus, the supply of vaccines for public health centers and private medical institutions
Chapter 4. Vaccine Supply Systems 071
are also different. The private medical institutions deal directly with the manufacturing
company/sales company or acquire their supply through a wholesaler. On the other hand,
public health centers currently acquire their supply of vaccines through a wholesaler that is
contracted with the public procurement service. This is different from the past when they
acquired their supplies directly from a manufacturing company or a wholesaler. However,
when there is an insufficient supply of vaccines in a public health center, the center may
purchase vaccines through its own regional wholesale company.
Although the vaccine budget was completely publicly funded in the past, after 1998 the
national government only bore 50% of the cost. Since 2005, the cost of the vaccination has
been completely supported by the health promotion fund.
2.1. Public Procurement Service

Vaccines used in public health centers are supplied through a wholesaler by means of a
vaccine supply contract. Normally, the national essential immunizations are issued every
year in January or February by the public procurement service to meet the demands of each
public health center. The vaccine contract determines the unit price and quantity.
The public procurement service does not cover the quantity purchased but the price itself
with the wholesalers. Each public health center requests purchases of specific vaccines
through the public procurement system. Then contractors (such as the wholesalers) deliver
the vaccine to the public health center. That is, the wholesaler is notified through the public
procurement site that it should supply vaccine to the public health center [Figure 4-1].
Figure 4-1 | Procedure for Domestic Vaccine Supply
[Health center vaccine supply]
Centers for Disease

Control and Prevention
Procurement
contract request
Notice cost of
the vaccine
Vaccine supply
Reimbursement for
cost of the vaccine
Medical institutions
Public health center

Vaccine supply
Manufacturer
(wholesaler)
Vaccine request
Auxiliary budget
Manufacturer
(Wholesaler)
Centers for Disease

Survey of demand
Vaccine supply
Payment
Vaccine request
Public
Procurement Service
Sign contract
Contract notice
Survey of Demand
Payment
[Private institution vaccine supply]
2.2. Wholesalers
The wholesaler supplies vaccines to the private medical institutions through a separate
contract. When the private medical institutions request a vaccine, they deliver the vaccines
directly to a hospital or clinic. Also in the case of medical institutions in remote areas, the
wholesaler or distributer firms that are located in adjacent regions deliver vaccines instead
of the original contracted wholesaler.
If there is waste at the hospital or clinic, it is turned over to the wholesaler who supplied
it. It is then delivered to the respective manufacturing company and wholesaler and is
discarded.
2.3. Manufacturers
Manufacturers can be broadly divided into multinational pharmaceutical companies and
domestic pharmaceutical companies. Multinational pharmaceutical companies perform
most of their distribution through domestic vendors. Along with domestic vendors, vaccines
are also supplied through wholesalers.
The domestic manufacturing companies supply their vaccines directly from the company
or through a wholesaler. Yet, the pharmaceuticals do not directly deliver the vaccines to
public health centers. Instead, after procurement contracts are signed with the government,
the wholesaler acts on behalf of the pharmaceutical companies. As they handle the delivery,
the vaccines are completely supplied through a third party bidding. In response to the
requests from each public health center, the vaccine supplier purchases the various vaccines
from the manufacturer and delivers the vaccines to public health centers nationwide. The
manufacturing company will pay the vendors prescribed margins and distribution costs.
3. Vaccine Supply Monitoring System

Since 2012, a system to monitor vaccine supplies has been developed on the internet.
The Korea Centers for Disease Control and Prevention Vaccine Supply Monitoring System
tracks the status of vaccine supplies at health centers in real time. It also makes immediate
response to vaccine shortages and is connected to the Immunization Registry Information
System (IRIS). The Vaccine Supply Monitoring System can be accessed through IRIS
(http://is.cdc.go.kr) and important information such as vaccine supply status, lot-specific
receipt/factory registry details, vaccine status statistics, and the status of optimum/minimum
reserves are offered on the website. However, only public health centers can use the vaccine
monitoring system. As private medical institutions purchase the vaccines directly, they do
not need to use the system [Figure 4-2].
On the basis of preset immunization plans, public health centers are assigned to optimum
and minimum holdings of vaccines. By entering the amount of vaccine warehousing, the
government can automatically see the status of the vaccine supply through the computer
system at the national, city, and public health care center levels.
Figure 4-2 | Screenshot of the Vaccine Monitoring System
4. Implications
There are a limited number of vaccine manufacturing companies, unlike manufacturing
companies for general pharmaceuticals. The targets of immunizations do not exceed a
limited number while extensive time and resources are spent to develop the medicine used
for vaccines. Therefore, special management is required. Korea has a very low level of
self-sufficiency with respect to vaccines. As a result, there are difficult structural limitations
to respond flexibly to the needs of epidemics or other large-scale demands. Furthermore,
except for the vaccine supply for the public health centers, the supply for private medical
institutions is furnished on the private market. Still, there are limitations to identifying the
exact scale of the supply or managing the national supply of vaccines. Fortunately however,
the country is relatively small and densely populated, so there is little difficulty in the
distribution and management of vaccines.
Recently, a variety of alternative plans for the vaccine supply have been suggested. In
the long term, the national government will have to manage the supply of vaccines for
children. For this, the national government will have to purchase all required vaccines. The
prevailing opinion is that the government would then need to distribute the vaccines on the
private market. Fortunately, the computerized immunization system that begun in 2009 will
allow relatively accurate analysis of the immunization supply in Korea in the near future.
Based on these results, it will be possible to identify the exact demand for vaccines and set
up plans to meet such demands. In this way, an effective system for managing the vaccine
supply can be devised. In addition, private medical institutions and public health centers can
improve their dual supply systems. It is also important to establish an organization at the
national level that is in charge of supplying vaccines.
Originally, the cost for childhood immunizations was completely borne by the national
government. However in 1998, the national governments share was reduced to 50%.
Beginning in 2005, the cost of vaccines was not covered by general appropriations but from
the Health Promotion Fund. In light of the important responsibilities of the state with regard
to childhood immunizations, it would be quite natural to cover the immunizations costs
from national general taxes. However, immunizations are currently funded by the Health
Promotion Fund, which is not directly related to tax collection. It would be much better
if the immunization budget were shared between the national and local governments and
supported through taxation.

Chapter 5
Immunization Reporting Systems
1. Immunization Registry Information System

2. Immunization Certification for School Entry
3. Adverse Reaction Monitoring System
4. Infectious Disease Surveillance System
Immunization Reporting Systems
1. Immunization Registry Information System

1.1. Introduction
The most important factors in immunization are as follows: that a greater than optimum
ratio of total population receive vaccinations, and that they receive vaccinations while
maintaining proper immunization intervals for the appropriate age brackets so that every
individual can have optimum immunity. In order to determine and maintain precise
immunization rates and the timeliness of immunization, every individuals immunization
record should be registered and accessible in real time. Computerization is essential for
managing these records because through an online system, information can be exchanged
and same records can be effectively shared in real time. In fact, the lack of individual
immunization information makes optimal management difficult. This can become an
obstacle in preventing infectious diseases, making complete immunization unachievable.
For this reason, as a preparatory step towards the management of target groups and
elimination of infectious disease through precise immunization information, the Korea
Centers for Disease Control and Prevention has developed a program to computerize and
manage all immunization records and has been promoting the National Immunization
Registry Information System (IRIS) since 2002. In the initial stage, IRIS was promoted
in all public health centers nationwide, and from 2004, it was expanded quantitatively and
qualitatively to include private medical institutions.
Despite its efforts to develop and spread the registry program, their participation is still
not satisfactory. This is mainly because of insufficient participation by private medical
institutions, which provided about 40% of routine immunizations nationwide until 2009.
The government body in charge of this project recognized the importance of enhancing
the quality of immunizations by collecting immunization records through IRIS. In order to
motivate private medical institutions to participate in the National Immunization Registry,
the government has begun to pay the vaccination fees of private hospital and clinic users.
2009 was a seminal year for Koreas national immunization program, with the introduction
of the reimbursement system for medical institutions. An opportunity to address many
of the weaknesses that had been observed over the years, this policy could solve problems
stemming from low level of participation by private medical institutions.
1.2. Project Promotion Progress

2000 - 2001 (only public health centers were registered)
- Since June of 2000, IRIS programs were installed in public health centers nationwide
and the computerization of individual immunization records began
2002 - 2005 (1st period)
- The Immunization Registry Information System(IRIS) was created
- Immunization Record Standardization Project: Standardized modules were supplied
to public health centers/private medical institutions and information was used
collectively
2006 - 2009 (2nd period)
- Database was constructed, expanded and improved
- Realization of the Infectious Disease Outbreak Prediction & Management System:
Provision of rudimentary data for R&D about virtual scenario analysis on disease
spreading, health policy establishment, vaccine development and effectiveness
assessment, etc., and realization of a geographic information system for vaccine
preventable disease (GIS VPD) prediction
- Reminder/recall service was expanded to cover all children
- Computer network was linked among related subdivisions of the Korea Centers for
Disease Control and Prevention
2012: The Korea Centers for Disease Control and Prevention system is linked with other
government department systems
- Resident registry information from the Ministry of Public Administration and

Security is linked
Chapter 5. Immunization Reporting Systems 079
- Immunization records are shared through a linkage with the Ministry of Education,
Science and Technology.
1.3. Project Promotion Strategies

The United States(Orenstein, et al., 1999) National Immunization Registry is operating
in order to carry out six main functions: monitoring individual immunization levels,
monitoring immunization levels in a given population group, reminding recipients and
their guardians of necessary vaccinations, recalling recipients for necessary vaccinations,
reminding medical staff if vaccinations are needed when patients visit medical institutions,
and identifying recipients of newly introduced vaccines.
Likewise, in South Korea, IRIS systematically collects and manages immunizationrelated data such as vaccines demographic characteristics, inoculation periods, and types
of vaccinations with the aims of qualitative enhancement of, record keeping for, supervision
of, assessment of, and research on immunization services. There are three main strategies
for ongoing advancement.
The first strategy is to help the quantitative and qualitative enhancement of immunization
rates.
The second strategy is to help improve the timeliness of immunization rates through
IRIS. In other words, IRIS distinguishes the vaccinated and non-vaccinated, makes a
list of recipients needing vaccinations, and utilizes it to trace and vaccinate them. With
IRIS established, the immunization rate increases as non-vaccinated individuals feel
a psychological burden from not being immunized and the reminder/recall function
automatically notifies them about their childrens immunization schedule.
The third strategy is to provide database for vaccine effectiveness assessments and the
immunization policy. In other words, with the linking of the National Immunization Registry
Information System (IRIS) and the Infectious Disease Outbreak Monitoring System, we can
determine the difference in the rates of infectious diseases between vaccinated and nonvaccinated groups. This offers crucial information for examining the effect of any given
vaccine as well as the necessity of certain policies. Moreover, this can be an important
tool for securing the reliability and quality of vaccines by collecting and analyzing adverse
reactions in a timely manner.
1.4. Project Promotion Accomplishments

In 2002, the first year in effect of the National Immunization Programs computerized
registry, 2,962,153 cases were registered. In fact, the number of cases increased every year.
In 2009, there were 2,962,153 cases, 8,030,961 cases in 2010, and 9,445,326 cases in 2011
<Table 5-1>.
Table 5-1 | Results of the National Immunization Programs Computerized Registry
(Unit: number of cases)
BCG
2002
2003
2004
2005
2006
55,540
74,946
94,416
92,136
94,809
2007
2008
2009
2010
2011
102,240 101,892 104,800 112,232 125,539
Hepatitis B
288,131 333,181 428,934 529,301 587,797 730,341 840,388 1,103,779 1,232,577 1,426,739
DTaP
679,619 766,474 935,769 1,050,164 1,174,488 1,388,640 1,602,539 1,817,990 1,861,739 2,282,780
Td
2,515
2,273
3,280
65,307
235,231 290,569 348,906 443,153 454,828 473,657
Polio
513,351 610,885 743,387 789,047 984,047 1,171,901 1,333,997 1,474,329 1,505,133 1,879,636
MMR
643,259 719,465 842,163 901,888 816,285 888,304 916,117 849,330 836,105 962,631
Japanese encephalitis 772,854 701,767 1,007,195 1,101,852 1,079,059 1,260,541 1,337,230 1,552,243 1,630,185 1,808,056
Varicella
Total
The rate of increase
compared to the
previous year
6,884
13,525
23,314
110,737 202,031 250,572 332,893 374,121 398,162 486,288
2,962,153 3,222,516 4,078,458 4,640,432 5,173,747 6,083,108 6,813,962 7,719,745 8,030,961 9,445,326
-
8.8
26.6
13.8
11.5
17.6
12.0
13.3
4.0
17.6
1.5. Project Promotion System

Private medical institutions can register immunization records in the computer database
in two ways. The first way is to login to the immunization registry of KCDCs web-based
Portal System (http://is.cdc.go.kr). The second method involves linkage of the Electronic
Medical Records System (EMR) used by private medical institutions to the standardized
module. After logging in to KCDCs Portal System (http://is.cdc.go.kr), whenever additional
immunization-related information is registered, such records are simultaneously saved
in the computer database, and this information can be accessed by medical institutions.
Since the Portal System of the KCDC can only be used by medical institutions that have
authorized access, institutions must apply for online registration. After the public health
center approves its registry, the institution has the authority to use the system. When this
process is finished, institutions can use the system by logging in with their ID/password and
officially recognized authentication certificate [Figure 5-1, 2, 3].
The data collected in the National Immunization Registry consists of three sets: the
vaccinees information, the guardians information, and immunization history. The vaccinees
information includes the vaccinees name, personal identification number,7 zip code, address,
home phone number, and cell phone number. The guardians information, including name
and resident registration number, is temporarily used in order to distinguish newborns before
their resident registration numbers are issued. Immunization history data is used to verify
whether all the core vaccinations were given, if any other shots are needed, and which
vaccines caused adverse reactions. This data includes the vaccine name, date of vaccination,
vaccinated body part, method of vaccination, dosage, order of vaccination in the vaccine
series, and vaccines lot number <Table 5-2>.
Table 5-2 | Types of Information Gathered in the Immunization
Registry Information System
Type of information
Data
Vaccinee information
Name, personal identification number, zip code, address,

home phone number, cell phone number, e-mail
Guardian information
Name, personal identification number
Vaccination information
Vaccine name, date of vaccination, vaccinated body site,

method of vaccination, dosage,
order of vaccination in the vaccine series, vaccines lot number
7. This number is similar to the social security number used in some other countries.
Figure 5-1 | Screenshot of the Portal System of the KCDCs Immunization Registry
Information System
Figure 5-2 | Screenshot of an Immunization Record Registry accessed through

the Immunization Registry Information System
Figure 5-3 | Screenshot of an Immunization Record Registry accessed through

a Private Medical Institutions Electronic Medical Recording System (EMR)
1.6. Legal Reporting Responsibility

Responsibility of legal reporting (i.e. filing and reporting vaccination records) is stipulated
in Article 28 of the Prevention and Management of Infectious Diseases Act. Mayors, heads
of counties, and heads of districts are responsible for drawing up and filing immunization
records when required immunizations and recommended optional immunizations are
carried out or when they are reported from other medical institutions. The documents are
to be reported to the mayor, provincial governor, and the Minister of Health and Welfare.
When an individual (i.e. private doctors, medical officers) other than the mayor, head of
the county, or head of the district administers vaccinations, such cases must be reported to
the mayor, county head, or district head on a monthly basis. Immunization records can be
registered online via KCDCs Portal Systems (http://is.cdc.go.kr) mmunization registry
system and they can also be reported through paper documents. The report should include
personal data about the vaccinee and guardian, as well as detailed vaccine information.
1.7. Implications
At first, the Immunization Program was to focus on quantitatively enhancing the
immunization rate through mass vaccination. However, now that a broader immunization
rate has been secured, its focus has changed. The current goal is not only to control the
qualitative immunization rate at the individual level but also to search for individuals who
have not received immunizations, make them get vaccinations, and raise the prevention
level of preventable infectious diseases up to elimination.
The Immunization Registry Information System has been successful for several reasons.
Medical institutions had long before computerized their own medical records. Beyond being
merely responsible for reporting records, private medical institutions were encouraged to
participate in the National Immunization Program through the governments funding of
immunization costs. This encouraged a considerable number of people who previously
got vaccinated only at public health centers to now visit nearby medical institutions for
their vaccinations. In 2009, when H1N1 influenza suddenly broke out and the vaccine
was in short supply, the National Immunization Registry Information System was used to
encourage members to reserve vaccinations beforehand and get inoculated on their reserved
date. This system helped to effectively deal with short supply.
At present, nearly all newborn infants are being registered in the database, and presumably
the national immunization rate will soon be calculated. Moreover, through the linkage with
resident registration information, we can find children who are omitted from immunization
records in real-time and therefore, can individually manage those who are missing.
2. Immunization Certification for School Entry

2.1. Introduction
In the past, parents or guardians in Korea were legally obligated to immunize their
children. From 1999, however, the policy changed so that guardians could voluntarily
immunize their children. Such change from mandatory to voluntary immunization was to
signify the autonomous decision making of individual citizens, who greatly value personal
choice regarding health matters. However, there is still a responsibility not to cause harm
to others health when entering a social group involving communal interaction, such as at
school. Therefore, despite holding the citizens right to autonomous decision making, there
is a responsibility to get vaccinated in certain situations. The representative policy for this
situation is the Immunization Certification for School Entry.
The Immunization Certification for School Entry is a highly effective policy to enhance
and maintain immunization rates. It is very difficult, however, for children to get issued and
turn in immunization certificates for all the national core vaccinations. In other words, since
100% of vaccination records have not been logged into the computer database, there is an
obstacle of having to visit each immunization center one by one to get ones immunization
certificate issued and submitted. Owing to these restrictions, from 2001 to 2011, the
government only verified whether children had received the second dose of the measles
vaccine.8 In 2012, immunization verification expanded to include 4 types of additional
vaccinations for school children aged 4 to 6.

2.2.1. Project Subjects
The targets of this project are children who are about to enter elementary school. There
are 4 types of booster vaccinations for children ages 4 to 6: the fifth dose of DTaP, the fourth
dose of polio, the second dose of MMR, and the fourth dose of inactivated vaccine (or third
dose of live attenuated vaccine) of Japanese encephalitis.
2.2.2. Project System

a. Mayors, County Heads, or District Heads
These public officials issue notices concerning the immunization certification for school
entry.
b. Parents
Before their children enter elementary school, parents should check whether their
immunization records are registered in the database and have any omitted vaccinations
completed.
c. Elementary School Principals
Principals use the National Education Information System (NEIS) to check whether new
students have been vaccinated and supervise the vaccination of unregistered students.
d. Public Health Centers
The School Children Immunization Completion Status submitted by the school is
registered on the Immunization Completion Status Management page of the School Children
8. The measles epidemic that had just occurred in the year 2000 motivated the formation of some degree
of social consensus regarding the need for immunizations.
Immunization Verification Systems website (http://is.cdc.go.kr). Submitted immunization

certificates are registered at the certificate management registry page of the School Children
Immunization Verification Systems website (http://is.cdc.go.kr).
e. Other Responsible Parties
The Korea Centers for Disease Control and Prevention is in charge of drawing up and
issuing project guidelines, creating and distributing project PR materials, and linking
its computerized data bases of the Ministry of Education, Science and Technology. The
Ministry of Education, Science and Technology and the Office of Education are responsible
for establishing systems so that elementary schools can verify immunization records sent
from the Korea Centers for Disease Control and Prevention using the National Education
Information System (NEIS). They are also responsible for advertising in local communities
as well as monitoring the immunization status of each school. The Ministry of Public
Administration and Security is in charge of distributing the School Children Immunization
Notice to the respective town (eup), sub-county (myeon), and village (dong) who, in turn,
issue the notices. The ministry also encourages PR through newsletters and the local media.
Figure 5-4 | Project System for Immunization Certification for School Entry
Student/Guardian
Guiding non-vaccinated individuals
Confirmation of
vaccination
Confirmation of
Vaccination
Request for vaccination
records registration
Immunization
Provider
Elementary School/
Office of education
Immunization
Registry Information
System
Immunization
records
Registration
Request for
vaccination rate
confirmation of
individual school
Immunization
records
Registration
Submission of
Vaccination rates
2.2.3. Legal Basis

The Prevention and Management of Infectious Diseases Act and the School Health Act
stipulates that mayors, county heads, and district heads may request elementary and middle
school principals to submit medical records concerning the completion of immunization.
Institutions such as kindergartens and daycare centers may also ask parents to submit
immunization record verification. Moreover, any preschoolers or students who have not
completed their vaccinations should be immunized.
2.3. Implications
The Immunization Certification for School Entry project can be seen as a policy that
has two sides: the perspective of protecting the population from infectious diseases and the
perspective of securing citizens rights to personal liberty. Even though immunization is
socially necessary, it cannot be forcibly carried out while ignoring ones personal liberty.
However, if all immunization-related decisions were solely made by the individual, the social
losses due to infectious diseases could be enormous. Accordingly, when immunizationrelated decisions come down to individual free will, this policy ensures that individuals
fulfill the minimum level of social duty when entering social institutions such as schools.
Korea introduced the Immunization Certification for School Entry system due to
sufficient quantitative and qualitative - civil awareness of immunization. Other important
reasons for introducing this project are as following: it helps finding omitted immunization
information, it helps completing uncompleted vaccinations, and it helps encouraging people
to complete their vaccinations on an individual basis.
3. Adverse Reaction Monitoring System

3.1. Introduction
Immunization is known as the most cost-efficient health project for preventing many
infectious diseases (World Development Report, 1993). When the immunization rate in
a local community is maintained above 95 percent, vaccination can decrease the rate of
preventable infectious diseases outbreak. Moreover, immunization can be regarded as one
of the most important health policies from the economic perspective, since the benefits of
immunization are about 4-30 times greater than the cost (CDC, 2001). After immunization,
however, adverse reactions occur inevitably and unfavorable results happen unexpectedly.
Adverse reactions to vaccinations are difficult to predict and, even when they occur,
a direct connection with the vaccine is difficult to establish. Infants under six months,
the main recipients of vaccinations, are particularly vulnerable to diseases due to their
fragile immune system. Hence, it is difficult to establish a direct causal relationship with
the vaccination if an infant contracts a disease after being inoculated. However, if citizens
avoid immunization because of excessive anxiety over such adverse reactions, a decrease
in the immunized population can lead to the spread of infectious diseases. As this could
threaten the health of the entire country, measures for post-immunization problems are
being prepared and implemented at the national level.
In the United States, the increase in adverse reactions caused by the whole-cell Bordetella
pertussis component in the DPT vaccine in the 1970s led to the first public discussion over
injury compensation policies. Pharmaceutical companies abandoned vaccine manufacturing
due to the increase in lawsuits, which led to problems with the vaccine supply. In 1986, the
National Childhood Vaccine Injury Act (NCVIA) was passed, and based on this Act, the
National Vaccine Injury Compensation Program (VCIP) was introduced.
Korea confronted with adverse reactions issues after the Japanese encephalitis
vaccination in 1994. Accordingly, to lay the legal groundwork for infectious disease
prevention measures, Korea set up the national compensation program for vaccine injury in
August of that year.
3.2. Project Promotion Process

1994: Legal basis for a National Compensation Policy is established and the Postimmunization Adverse Reaction Monitoring System is introduced.
2000: The Electronic Document Interchange (EDI) reporting methods for postimmunization adverse reaction is introduced.
2001: The Vaccine Injury Compensation Inquiry Committee is established and begins
operation. Medical reporting of post-immunization adverse reactions becomes
mandatory.
2003: The Vaccine Injury Investigation Unit is established.
2005: A web-based reporting method for the post-immunization adverse reaction
reporting system is introduced.
2010: Name changed to Vaccine Injury Compensation Expert Committee

3.3.1. Adverse Reaction Monitoring System
The post-immunization adverse reaction monitoring system can be mainly divided into
two parts: the passive monitoring system and the active monitoring system. Due to its lower
cost, the passive monitoring system has been used as the basic apparatus for the adverse
reaction monitoring system. In the past, the system was run by vaccine manufacturers, but
nowadays, it is operated at the national level. In the US, the Centers for Disease Control
and Prevention (CDC) and the Food and Drug Administration (FDA) have jointly operated
the Vaccine Adverse Event Reporting System (VAERS) since 1990 and have also run the
Vaccine Safety Datalink (VSD) as part of the active monitoring system. Since 2005, with
the linkage of the health insurance system and the introduction of Rapid Cycle Analysis
(RCA), adverse reactions have been quickly monitored.
In 2000, Korea consolidated a national safety control system for immunization consisting
of rapid countermeasures for post-immunization adverse reactions, early-period monitoring,
scientific epidemiological research, and injury compensation. For a prompt countermeasure
system, the Post-immunization Injury Investigation Unit (Formerly Post-Immunization
Adverse Reaction Council) was established to make decisions about a vaccines scope
and whether to temporarily suspend the use of a vaccine when the vaccine causes serious
adverse reactions such as death [Figure 5-5].
Currently in Korea, post-immunization adverse reaction monitoring is carried out through
the diagnosis and reporting of doctors (http://is.cdc.go.kr) or through the monitoring by
guardians (http://nip.cdc.go.kr). When doctors diagnose or examine a post-immunization
adverse reaction, they must immediately report it to a public health center via phone, fax, mail,
or online (http://is.cdc.go.kr). Personal data, the date of vaccination, the medical institution
that provided the vaccination, relevant information about the vaccine, immunization record
(immunizations administered within the past 4 weeks), unusual details before immunization,
the date of the adverse reaction occurrence, the type of adverse reaction, and the progress
of the adverse reaction should be included in the report. Guardians who suspect an adverse
reaction may report it online or to a public health center [Figure 5-6]. Thereafter, reported
data is collected and analyzed through the post-immunization adverse reaction integrated
monitoring system and shortly after, the warning system is activated.
Figure 5-5 | National Safety Management System for Adverse Reactions
Rapid Response System

Vaccination Injury Investigation Unit
Epidemiological investigation command
and rapid response in cases of severe
adverse reactions
Measures for the temporary suspension of
vaccine
Establishment of a cooperative system
and related institutions
Monitoring System of Post-immunization

Adverse Reaction
Epidemiological Investigation System for

Post-vaccine Adverse Reaction
National Safety
Control System
for Vaccinations
Doctors, Guardian, Manufacturer reporting

Safety investigation when vaccines enter
the market
Recognize incidence and assess the state
of adverse reaction
National and Provincial Epidemiological

Investigation Unit
Determine cause of adverse reaction
Evaluate safety of vaccine and apply in
monitoring
Application in further basic research data
National vaccine injury compensation

Program
Vaccine Injury Compensation Expert
Committee
Vaccine Injury Investigation Unit
Social compensation for vaccine injury
Third-party objective injury investigation
Figure 5-6 | Adverse Reaction Reporting System
Reporting
Patient or guardian
Reporting by
Telephone
Public
health
center
Doctor
Receiving
Immunization Guide site
Reporting by
Telephone
Feedback of
results
City/
province
Reporting by
Telephone
Feedback of
results
the Korea Centers for

Disease Control and
VPD Control & NIP
Reporting by
Telephone
Online Reporting
Online
Online
Reporting
Reporting
Portal system of KCDC
Receiving
3.3.2. Epidemiological Research on Adverse Reactions

Since there are a variety of causes and types of adverse reactions that occur after
immunization, an adverse reaction can be classified by its frequency of occurrence, range,
severity, precipitating factors, etc. A vaccine not only contains antigens, but also other
materials such as suspension, antibiotics to prevent bacterial contamination during the
manufacturing process, stabilizers, preservatives, and immune boosters. These ingredients
are essential for the manufacturing of vaccines, but they can also cause adverse reactions.
Post-vaccination adverse reactions are generally caused by antigens with egg or egg-related
substances (in MMR and influenza vaccine), mercury-based medicine (in Hepatitis B, DTaP,
Japanese encephalitis, and influenza vaccine), stabilizers (in MMR vaccine), antibiotics
(in MMR vaccine), certain components of vaccine pathogens or some still unknown
components of vaccines. While adverse reactions can be caused by direct pharmacological
effects of these substances, hypersensitivity to the substances is a common cause.
Post-immunization adverse reactions can also be classified by the type of cause. (WHO
WPRO, 1999) The first type is a vaccine reaction, when the original substance in the
vaccine itself is the cause or trigger of the adverse reaction. Vaccine reactions are defined
as signs or symptoms caused or triggered by inherent properties of the vaccine, despite
the inoculation being properly performed. There are two types of vaccine reactions: minor
vaccine reactions, which are common, and serious vaccine reactions, which are rare. The
second type of post-immunization adverse reaction is procedural error, in which an adverse
reaction arises due to a procedural mistake, an error in the storage, preparation, or handling
of the vaccine. The following can be classified as procedural errors: inoculation of
a contaminated vaccine, improper preparation of a vaccine such as using the wrong
diluent, inoculation of the improper body part, improper distribution or storage, and
administration of a contraindicated vaccine. The third type of post-immunization adverse
reaction is a coincidental event, when a reaction arises. This happens coincidentally, and is
unrelated to the vaccine itself. The fourth type is an injection reaction, when pain or anxiety
occurs because of the inoculation procedure itself. The final type of adverse reactions is
when cause cannot be determined.
Therefore, epidemiological research is being conducted under the premise that there is a
need to establish the causes of adverse reactions by a trustworthy standard.
3.3.3. National Compensation for Immunization Injury

When one suspects that he or she has been injured from a vaccination, the vaccinee
or guardian can request compensation from the city, county or district administrations.
The Ministry of Health and Welfare (Korea Centers for Disease Control and Prevention)
will complete a compensation review through the Vaccine Injury Compensation Expert
Committee within 120 days of receiving the compensation request. The period during
which one can submit a petition is within 5 years after the injured party became aware of
the post-immunization adverse reaction.
Investigation process
- Primary investigation of injury: The mayor or provincial governor conducts an
investigation of the vaccination injury submitted by the claimant. Afterwards, the
results and comments of the primary investigation are sent to the Korea Centers for
Disease Control and Prevention.
- Detailed investigation of injury: The Vaccine Injury Investigation Unit examines

and evaluates the results of the primary investigation and carries out additional
investigation if necessary.
Indemnity coverage: medical bills, fixed nursing fee, temporary indemnity for the
disabled, temporary indemnity for the deceased, funeral service costs

In 2009, there were 2,380 reports of adverse reactions, 741 in 2010, and 238 in 2011. In
terms of injury compensation requests, there were 16 in 2009, 276 in 2010, and 71 in 2011
under the national compensation policy. Among the requests, 5 cases received compensation
in 2009, 113 cases in 2010, and 46 cases in 2011 <Table 5-3>.
Table 5-3 | Management Status for the National Compensation Policy for
Adverse Reactions
(Unit: number of cases)
Number of injury compensation requests

Year
Number of
reports of adverse
reactions
Number
of cases of
compensation
rewarded
Number of
rejections
Subtotal
2002
22
13
15
2003
25
2004
45
2005
364
13
18
2006
635
15
24
2007
515
13
21
Number of injury compensation requests

Year
Number of
reports of adverse
reactions
Number
of cases of
compensation
rewarded
Number of
rejections
Subtotal
2008
407
16
2009
2,380
11
16
2010
741
113
163
276
2011
238
46
25
71
Total
5,372
234
237
471
3.5. Implications
Compared to the history of the introduction of vaccinations, the injury compensation
policy for immunization-caused adverse reactions (the term side-effects was used in the
past) was late in becoming institutionalized. Because of this, however, Korea could analyze
and learn from the experiences and errors of other countries that had already implemented
such policies. Also, by developing and introducing a policy that fit domestic circumstances,
Korea could institutionalize it in a short period of time.
4. Infectious Disease Surveillance System

4.1. Introduction
Since the mid-1970s, the rate of acute infectious diseases has rapidly decreased as living
standards and levels of hygiene in Korea have improved. Since the beginning of the 90s,
however, global warming has brought a sudden increase in new and reoccurring infectious
diseases (Gayer, et al., 2007). Infectious disease has moved beyond a simple epidemiological
level and has risen as an important national economic and international health issue.
Recently, rather than being limited to particular locations or temporary outbreaks, the
spread of infectious diseases are frequently occurring over various regions. Through an
increase in traveling and the advancement of transportation systems, the possibility of an
influx of infectious diseases into the country from abroad is greatly increasing, making the
enhancement of the infectious disease management system even more important.
The World Health Organization (WHO) defines disease surveillance as systematically

collecting and using epidemiological data for planning, executing, and assessing disease
control. Through the infectious disease surveillance system, infectious disease incidence
information can be used for disease management and prevention by continuously and
systematically collecting, analyzing, and circulating it. Ultimately, the surveillance system
holds great importance as the system for infectious disease outbreak countermeasures.

1954 (passage of the Infectious Disease Prevention Act): The Infectious Disease
Surveillance System is
introduced.
2000 (the Act is renewed): c lassification standards and types of nationally notifiable
communicable diseases

standardization of reporting
introduction of a sample surveillance system
the surveillance system is strengthened by the establishment of

the Infectious Disease Surveillance Information System(EDI
program)
2007: Online Infectious Disease Surveillance Information System and Online Statistical
System are established.
2009: The Medical Institution Reporting System is established via the Online Information
System.

4.3.1. Infectious Disease Surveillance System
Surveillance is the total process of systematically and consistently collecting,
analyzing, and interpreting data related to the outbreak of infectious disease and its vector,
and distributing the results to the people who need it at the proper time so that it can be used
to prevent and manage infectious diseases. The objectives of infectious disease surveillance
are 1) to predict the magnitude of the problem caused by any given disease, 2) to observe the
progress of the disease incidence, 3) to confirm the outbreak and spread of a disease within a
population, and 4) to pinpoint new problems and apply this information for prevention and
management purposes.
The occurrence of Category I, II, III (except influenza), and IV nationally notifiable
communicable diseases requires immediate reporting. Category III and V influenza and
specified communicable diseases are notified on a weekly basis [Figure 5-7].
Moreover, the infectious disease statistics website (http://stat.cdc.go.kr) is a public

website that provides statistics on infectious disease cases. Whoever has internet access
can get precise and rapid information on the number of cases regarding the occurrence
of infectious diseases. The information on the website covers Category I, II, III, and IV
nationally notifiable communicable diseases and specified communicable diseases. It is
updated every day, giving users information in real-time.
Figure 5-7 | Reporting System for Nationally Notifiable Communicable Diseases
Korea Centers for Disease

Department of Communicable
Disease Surveillance
(Korea National Institute of Health)
Reporting
Feedback of results
(Clinical specimen request)
Feedback of results
Metropolitan city-Provincial
Institute of Health and
Environment
Metropolitan city-Provincial
Health Department
Reporting
Feedback of results
City-County-District
Health Centers
(Clinical specimen request)

Feedback of results
Reporting of
communicable
disease incidence
Feedback
of results
Reporting of
communicable
disease incidence
Sample Surveillance Medical institution
Feedback
of results
Physician, Oriental medicine doctor,

Chairperson of a medical institution,
commanding officer (military doctor)
4.3.2. Sample Surveillance System for Infectious Disease

Sample surveillance of infectious disease is being carried out in order to observe the
outbreak progress and predict the spread of infectious diseases. The infectious diseases
covered by sample surveillance are Hepatitis C, hand-foot-and-mouth disease with
complications, sexually transmitted diseases, infectious diseases from foreign parasites,
influenza, parasitic infectious diseases, medical treatment-related infectious diseases,
internal infectious diseases, acute respiratory infectious diseases, and enteroviral infectious
diseases. Within 7 days of its occurrence, the infectious disease should be notified, and
reported once a week. The reporting system is as follows: the sample surveillance institution
reports to public health centers via a website (http://is.cdc.go.kr) or fax, the public health
centers report to the metropolitan city or province via the web, then the city or province
reports to the Korea Centers for Disease Control and Prevention via the web.
a. Influenza Sample Surveillance System

The objectives of the Influenza Sample Surveillance System are to monitor the trends in
influenza outbreak cases, analyze demographic features and detect an outbreak at the early
stage through actively surveilling diseases, monitoring the emergence of new viruses by
isolating the prevalent influenza virus, and predicting the effects of current vaccines and
outbreak patterns in order to establish a national influenza management organization.
b. Infant Sample Surveillance System
Run by primary care physicians and pediatricians in local communities, the Infant Sample
Surveillance System has the aim to observe outbreaks and predict the spread of infant
diseases. This sample surveillance covers meningitis, classified in the other infectious
diseases category, as well as Category II national notifiable communicable diseases measles, mumps, rubella, and varicella.
c. Ophthalmological Sample Surveillance System
The Ophthalmological Sample Surveillance System is managed by primary care
ophthalmologists in the local community for observing the incidence and predicting the
spread of ophthalmological diseases.
d. Sample Surveillance System for Infectious Diseases at Schools
To predict and observe disease occurrence, the Sample Surveillance System for Infectious
Diseases at Schools is managed by school nurses/health teachers in charge of school health.
The number of students absent due to the cold/influenza, varicella, cerebromeningitis,
conjunctivitis, mumps, pneumonia, and measles, and those who visit the nurses office due
to cold symptoms are reported.
4.3.3. Other Surveillance Systems

Monitoring of other infectious pathogenic organisms, laboratory monitoring of acute
diarrhea, and systems monitoring infectious diseases from abroad are also being performed.

4.4.1. Incidence Rate of Acute Infectious Diseases
The highest disease incidence rate was in 1962 with 222.9 cases per 100,000 individuals.
It steadily decreased until the mid-1990s. However after the late-1990s, the incidence rate
increased again and in 2000, it reached 93.9. This seems to be due to the spread of measles,
bacillary dysentery, and the reoccurrence of malaria. In 2003, the incidence rate decreased
to 13.2 but began to rise again in 2004. This could have resulted from the increase in autumn
pyrogenic diseases (mostly scrub typhus) and zoonosis (mostly brucellosis). The fact that
malaria, which had been decreasing, rebounded somewhat in 2005, and that varicella,
newly added to the nationally notifiable communicable diseases in July of 2005, likely have
contributed to such increase.
Incidences of infectious diseases soared during 2009 and 2010 as influenza A/H1N1
spread globally. Exempting influenza A/H1N1, the incidence rate of acute infectious
disease was 79.0 cases per 100,000 in 2009 as well as in 2010, having trended upward since
2004. In 2011, the incidence rate increased to 117.3 cases, as hepatitis A and B and syphilis
were transferred from sample surveillance to nationally notifiable communicable disease
surveillance <Table 5-4>.
Table 5-4 | Incidence Rate Trends for Acute Infectious Diseases
(Unit: per 100,000 people)
Year
65 75 85 95 99 00 01 02 03 04 05 06 07 08
09
10
11
Acute
infectious
disease 65.3 29.4 8.7 3.6 21.7 93.9 67.2 13.8 13.2 18.5 27.7 48.1 71.1 72.8 1,502.6 192.4 117.3
incidence
rate
4.4.2. Current Status of (Category II) Vaccine Preventable Diseases

The highest number of Category II infectious disease cases reported was varicella,
followed by mumps and hepatitis B. Reports of varicella have notably increased after being
designated as a nationally notifiable communicable disease in 2005. Thanks to ongoing
education and publicity efforts since its designation, more people have reported incidences
and this led to the increase in the reporting rate. For pertussis, a project for monitoring adults
started and consequently, notification rates and occurrence reports increased. Likewise,
mumps, which up until 2009 had showed an increase, leveled off afterwards.
After the large scale measles outbreak in 2001, a mass immunization project kept
incidence rates at eradication levels. However, the number of cases rose to 194 in April
2007 after an outbreak that began in a hospital spread to the local community. In 2008, its
incidence rate was near eradication levels, but a 2010 outbreak at a school saw it rise again
to 114. An influx from abroad in 2011 led to a small outbreak that centered around Changwon, South Kyungsang Province (KyungsangNamDo).
The incidence of Japanese encephalitis had stayed below 10 individuals per year until
2010, when 26 cases were reported. This was the highest incidence rate since 2000, yet in
2011 it decreased again to a mere 4 cases <Table 5-5>.
Table 5-5 | Incidence of (Category II) Vaccine Preventable Diseases
(Unit: number of reports)
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Pertussis
21
11
17
14
66
27
97
Tetanus
11
11
10
16
17
14
19
Measles
23,060
62
33
11
28
194
17
114
42
Mumps
1,668
764
1,518
1,744
1,863
2,089
4,557
4,542
6,399
6,094
6,241
Rubella
128
24
15
12
18
35
30
36
43
54
Hepatitis B
2,944
4,998
9,214
9,731
7,998
8,214
8,574
7,202
5,566
5,085
1,781
Japanese
encephalitis
26
Varicella
1,934
11,027 20,284 22,849 25,197 24,400 36,356
4.4.3. Status of Cases Reported through the Mandatory Surveillance

of Nationally Notifiable Communicable Diseases
The total number of reported infectious disease patients in 2011 was 98,717 (195 per
100,000 individuals). This was a 26.1% decrease (34,842 individuals) compared to that
of the previous year (2010) with 133,559 (266 per 100,000). The infectious disease with
the highest incidence in 2011 was tuberculosis with 39,557 cases (40.1%), followed by
varicella with 36,249 cases (36.7%). In 2011, after tuberculosis and varicella, mumps with
6,137 cases (6.2%), hepatitis A with 5,521 cases (5.6%), and scrub typhus with 5,151 cases
(5.2%) followed. The top-five highest incidence infectious diseases comprised 93.8%
(92,615 cases) of all 2011 infectious disease cases.
In terms of acute and chronic infectious diseases, 58,265 acute disease cases were reported
in 2011. There was a 39.6% decrease compared to that of the previous year (2010) with
96,475 people. For chronic disease cases, 40,452 cases were reported in 2011, including
tuberculosis, Hansens disease and AIDS: a 9.1% increase compared to that of the previous
year (2010) with 37,084 people <Table 5-6>.
Table 5-6 | Reporting Status of Incidences via Mandatory Surveillance of Nationally

Notifiable Communicable Diseases
2005
2006
2007
2008
2009
2010
2011
Cholera
16
Typhoid
190
200
223
188
168
133
148
Paratyphoid
31
50
45
44
36
55
56
Bacillary dysentery
317
389
131
209
180
228
171
Infectious disease from

enterohemorrhagic E. coli
43
37
41
58
62
56
71
Hepatitis A
5,521
Pertussis
11
17
14
66
27
97
Tetanus
11
10
16
17
14
19
Measles
28
194
17
114
42
Mumps
1,863
2,089
4,557
4,542
6,399
6,094
6,137
Rubella
12
18
35
30
36
43
53
acute
462
462
maternal
1,183
1,183
perinatal
30
30
Japanese encephalitis
26
Varicella
1,934
11,027 20,284 22,849
25,197
24,400
36,249
Malaria
1,369
2,051
2,227
1,052
1,345
1,772
838
Scarlet fever
87
108
146
151
127
106
406
11
12
Pittsburgh pneumonia
20
19
21
24
30
28
Vibrio sepsis
57
88
59
49
24
73
51
Murine typhus
35
73
61
87
29
54
23
Scrub typhus
6,780
6,480
6,022
6,057
4,995
5,671
5,151
Leptospirosis
83
119
208
100
62
66
49
Brucellosis
158
215
101
58
24
31
19
Rabies
Korean hemorrhagic fever
421
422
450
375
334
473
370
Stage 1
690
State 2
235
Congenital
40
Hepatitis B
Syphilis
Creutzfeldt-Jakob disease
(CJD)
Tuberculosis
2005
2006
2007
2008
2009
2010
2011
29
35,845
36,305
39,557
35,269 35,361 34,710 34,157
Hansens disease
38
56
12
AIDS
680
749
740
797
768
773
888
Dengue fever
34
35
97
51
59
125
72
Botulism
Q fever
12
19
14
13
H1N1
706,911
56,850
Lyme disease
Melioidosis
Leishmaniasis
Babesiosis
Cryptosporidiosis
Schistosomiasis
782,754
133,559
98,717
Total
49,467 59,665 70,416 70,941
1) All reporting of patients, doctor-patients, and pathogen carriers were included
2) Diseases which are not reported as incidences, such as diphtheria, polio, typhus fever, anthrax, pest, yellow
fever, viral hemorrhagic fever, small pox, severe acute respiratory syndrome (SARS), avian influenza virus
infectious disease, H1N1, rabbit fever, West Nile fever, tick-borne encephalitis, and Chikungunya fever, are
excluded
4.4.4. Status of Reporting Deaths due to Nationally Notifiable

Communicable Diseases
The number of deaths reported due to nationally notifiable communicable diseases was
7 in 2010 and 536 in 2011. In 2011, Category III tuberculosis was reported as the cause
of death of 340 people (63.4%), which accounted for the greatest amount of total cases,
followed by 148 cases (27.6%) of death due to AIDS and 26 cases (4.9%) of death due to
Vibrio sepsis <Table 5-7>.
Table 5-7 | Reports of Deaths due to Nationally Notifiable Communicable Diseases

Name of disease
2010
2011
Cholera
Typhoid
Hepatitis A
Tetanus
Rubella
Malaria
Tuberculosis
340
Pittsburgh pneumonia
Vibrio sepsis
26
Scrub typhus
Korean hemorrhagic fever
AIDS
148
Syphilis (Stage 1, Stage 2, Congenital)
Creutzfeldt-Jakob disease
536
Group I
Group II
Group III
Total
4.5. Implications
In comparison to other nations, Korea set up and began to operate specialized systems
for the surveillance of infectious disease occurrence quite late. However, the use of
developed information systems, in particular the internet, allowed the establishment of
precise surveillance systems in a relatively short period of time. Moreover, the usage of
the internet by all medical institutions and the establishment of the electronic mandatory
recording system made a major contribution to the establishment of a web-based infectious
disease occurrence surveillance system. Thanks to this computerized surveillance system,
real-time information registration and sharing is now possible, along with the provision of
up-to-date information about infectious diseases.

Chapter 6
Immunization Success Stories
1. Hepatitis B
2. Measles
3. Pandemic Influenza A (H1N1)
Immunization Success Stories
1. Hepatitis B
1.1. Background
Approximately 90% of adults infected with hepatitis B can fully recover without any
difficulties. Conversely, the majority of infants infected with perinatal hepatitis B (from
28 weeks of gestation to 1 postnatal day) will not exhibit any symptoms. Nevertheless
90% of the infected infants will become chronic carriers, who in their 40s and 50s could
contract chronic hepatitis or cirrhosis. Either disease can lead to serious illnesses. Before
the dissemination of hepatitis B immunizations in Korea in the 1980s, a high percentage of
the population tested positive for hepatitis B surface antigen (HBsAg), specifically, 8-9%
of the men and 5-6% of the women (Ahn, 1982). As the illness is regarded as one of the
major causes of liver cancer, it was designated as a third class infectious disease in 1982.
Currently, it is classified as a second class infectious disease. Hepatitis B has been a target
on the list of national essential immunizations since 1995 [Figure 6-1].
Figure 6-1 | Important Programs for Managing Hepatitis B in Korea and Status of
Reduction of Individuals Who Tested Positive for Surface Antigen (Survey of Donors)
Implementation of regular
immunization for children
7.4
Proportion who tested positive for

the hepatitis B surface antigen
7
6
Beginning of project for the prevention of

perinatal hepatitis B transmission
5.2
5
4
Introduction of
the immunization
3
1.16
0.2
1
0
1983
85
1986
87
1989
90
1991
92
1995
97
1998
00
2002
03
2004
Source: C
enter for Disease Control and Prevention (2012), Information on Immunization Programs against
Perinatal Hepatitis B Infection in 2012, Center for Disease Control and Prevention (in Korean), p.5
One route of transmission of the hepatitis B virus (HBV) is from the mother to the infant
through perinatal infection. The hepatitis B virus can also be transmitted by such means as
blood transfusions (both blood and blood products), sexual contact, and needles. However, of
all these, perinatal exposure is the primary route of infection in Korea. The rate of pregnant
women tested positive for hepatitis B surface antigen (HBsAg) showed a slight decline as it
was 4.1% in 1990, 3.4% in 1995, and 3.2% in 2006. Every year, 15,000 infants have been
born exposed to the hepatitis virus (Chung, 2011). 65-93% of mothers of newborns who
tested positive for HBsAg transmitted the virus to their children and 90% of infected children
contracted a chronic infection. However, 75-80% of these cases can be prevented through
hepatitis B vaccine mono-therapy, and when this vaccine is administered with immunoglobulin,
95% of the cases can be prevented. Therefore, in terms of managing hepatitis B, it is very
important to prevent perinatal infection. The goals of the 2012 Korea Centers for Disease
Control and Perinatal Hepatitis B Infection Prevention Project are as follows:
Reduce the total population of those with hepatitis B surface antigen to 1% in 10 years.
Reduce the prevalence of chronic hepatitis B to 0.1%.
Reduce the incidence of liver cancer due to hepatitis B to 1/10th of the present rate
within 20 years.
Chapter 6. Immunization Success Stories 105
1.2. Program Progress Timeline

1983: Introduction of plasma-derived vaccine
1984: Domestic vaccine production
1985: Recommendation of the vaccine for those at high risk of contracting the disease
1987: Introduction of recombinant DNA vaccine
1987: Inclusion in the National Essential Immunizations list
2002: Introduction of a prevention program for perinatal hepatitis B
2007: Improvement of the computerized system for the prevention program for perinatal
hepatitis B
2008: Certification of achievements in managing hepatitis B from the Western Pacific
Regional Office (WPRO) of the World Health Organization (WHO)
2009: Production of an online manual on the hepatitis B perinatal infection prevention
program
2011: Certification of selected government innovation best practices for hepatitis B
management
1.3. Program Implementation Performance

According to the prevention program for perinatal hepatitis B infection, approximately
15,000 infants are infected every year. Of these children, 96.4% are registered and 14,000
have been treated <Table 6-1>.
Table 6-1 | Status of the Program for Initial Registry of Infants with Perinatal Hepatitis B
(Unit: persons, %)
Categories
2002
2003
(7-12)
2004
2005
2006
2007
2008
2009
2010
2011
Total
Newborns
exposed to the 7,857 16,678 16,074 14,791 15,237 15,783 14,909 14,235 15,045 15,084 145,693
infection
New registrants 5,394 14,586 15,410 14,411 15,002 16,483 15,266 14,547 14,760 14,976 140,835
Enrollment
coverage
68.7
87.5
95.9
97.4
98.5
104.4 102.4 102.2
98.1
99.3
96.7
Note: E
stimated exposure of newborns to perinatal transmission of hepatitis B in a given year = number of births in
that year x 0.032 x (births to women positive for surface antigen). Also, infants exposed in 2011 were based on
the 2010 figure for number of births. Mothers positive for surface antigen: 2002-06, 3.4%; from 2007, 3.2%
Medical institutions regularly used for infant delivery showed a high participation rate
in the prevention program for perinatal hepatitis B infection. Approximately 3600 private
medical institutions participated. In addition, 440 public health centers/health center
branches/health posts, 268 hospitals, 266 clinics, and 239 general hospitals participated in
the program <Table 6-2>.
Table 6-2 | Status of Medical Institutions Participating in Preventing Perinatal
Hepatitis B Infection
(Unit: institutions)
Year
General Hospital
Hospital
Clinic
Public Health Center
Total
2002
122
108
131
256
617
2003
191
205
317
418
1,131
2004
193
228
346
421
1,188
2005
199
243
329
435
1,206
2006
207
239
321
447
1,214
2007
203
247
309
496
1,255
2008
215
258
296
522
1,291
2009
210
243
271
556
1,280
2010
230
262
274
526
1,292
2011
239
268
266
440
1,213
Note: F
igures refer to medical institutions in which hepatitis B perinatal transmission prevention project coupons
were redeemed for immunization in a given year
1.4. Program Implementation System

1.4.1. Childbirth Delivery Facilities
a. Check the Individual Tests Positive for Hepatitis B Surface Antigen (HBsAg)
It is preferable for all pregnant women to get tested for hepatitis B in the early stages of
pregnancy. If the patient is at high-risk or concurrently exhibiting symptoms of hepatitis,
they are recommended to get a retest at the end of the pregnancy. If the woman tests positive
for hepatitis B surface antigen (HBsAg), the results should be verified with an HBeAg
test and the pregnant woman should be instructed on how to take measures to prevent
perinatal hepatitis infection. In order to receive the cost of the hepatitis B perinatal infection
measures back from the national government, a copy of the test results during the pregnancy
should be submitted to the child delivery facilities.
Figure 6-2 | Program to Prevent Perinatal Hepatitis B
KCDC
Database
Input
Inquiry
Public health centers
Public health centers
(Located in the area of mothers

resident registration address)
(Located in the area of private clinics)

Claim
(Submit coupons)
Private Clinics
Payment
Submit coupon
Infants born to
HBsAg[+] Mother
Provide prophylaxis services for

hepatitis B perinatal infection
[HBIG/vaccine, antigen/antibody tests]
Source: C
hung, CW (2011), Study of Perinatal Hepatitis B Prevention Programs in South Korea, Health and
Disease Weekly Center for Disease Control and Prevention 4(28), pp.498 (in Korean)
b. Hepatitis B Prevention Handbook Issued

- Issued to pregnant women who tested positive for HBsAg (including those who
tested positive for HBeAg)
- Handbook was issued immediately after delivery.
- Issued coupons so that the individuals could receive immunizations and examinations
according to the immunization schedule.
c. Immunoglobulin Immunization and First Hepatitis B Immunization
- 12 hours after birth, immunoglobulin immunization and hepatitis B immunization
d. Immunizations for Preterm Infants
- For preterm infants less than 2 kg and under 37 weeks
- Immunization at birth and preterm immunization coupons for booster shots, this is
for infants after one month (0-1-2-6 immunization schedule)
1.4.2. Immunization Facilities

a. Check Live Births of Mothers who have Tested Positive for Hepatitis B Surface
Antigen (HBsAg) and Training
- Questionnaire, asking about past immunization history and maternal disease history,
is administered when the hepatitis B immunization is given
- Verify targets through the guardians hepatitis B prevention booklet
b. Implementation of Second and Third Hepatitis B Immunizations
- Second hepatitis B immunization at 1 month old (at least 4 weeks after the first
immunization)
- Third hepatitis B immunization at 6 months old (at least 8 weeks after the second
immunization and at least 16 weeks after the first immunization)
c. Goals
Hepatitis B antigen and antibody tests (primary test)
- Subjects: Infants of mothers who tested positive for hepatitis B surface antigen
(HBsAg) who have completed the hepatitis B immunoglobulin and 3 hepatitis
immunizations as infants
- Implementation of antigen-antibody tests using the EIA, ECL, or CIA quantitative
methods at 9-15 months of age and after the infant has completed the basic course
of hepatitis immunizations
Hepatitis B immunization (first dose)
- Subjects: Based on the first hepatitis B antigen and antibody test, individuals who
do not have antibodies
- The first hepatitis immunization is administered within one week of obtaining the
test results
Hepatitis B antigen and antibody tests (secondary test)
- Second antigen-antibody test is administered at least one month after the first
hepatitis B immunization
Hepatitis B immunization (second and third doses)
- Subjects: Based on the second antigen-antibody tests for hepatitis B, individuals who
do not have any antibodies and receive coupons for the second and third hepatitis B
immunizations
- Third antigen-antibody test is administered
- Secondary antigen-antibody tests after the first immunization
1.4.3. Public Health Center

a. Management of Medical Facilities
Institutions for prenatal care
- Identify medical facilities that offer prenatal care under the local jurisdiction, and
cover publicity for the Perinatal Hepatitis B Infection Prevention Project
- Store examination results for women who have tested positive for hepatitis B surface
antigen (HBsAG) and educate them to submit the results to the childbirth delivery
facility when giving birth
b. Registration of Medical Institutions
New medical institutions should apply for registration at the public health center, and
be certified by the Korea Centers for Disease Control and Prevention.
c. Registration and Management
Targets of Registration: immunizations and examination coupons by a medical facility
that is under the public health centers jurisdiction
Registration method:
- In case of immunizations at the public health center, immunizations are verified
on the perinatal B hepatitis website after the individuals immunization history is
registered.
- If a pregnant woman registers at a medical institution that is under the jurisdiction
of a public health center, the pregnant womans information will be automatically
forwarded to her address and the fees for the immunization will be reimbursed and
sent to her address [Figure 6-2, 3, 4].
Figure 6-3 | Procedures in the Program to Prevent Perinatal Hepatitis B Infection
Schedule
Mother and infants
Before delivery
Within 12
hours of
the delivery
At a child delivery facility,

immunoglobin and first
hepatitis B
Booklet issued by
management
1 month
after the
first dose
1 month after
birth
Visit immunization facility

for second hepatitis B
immunization
Present coupon in lieu of
immunization fee
1 month
after the
second dose
6 months
after birth
Visit immunization facility

for third hepatitis B
immunization
Present coupon in lieu of
immunization fee
1 month
after the
third dose
Medical institutions
Mother keeps the hepatitis

B immunization booklet
given from Health center
Hepatitis B booklets
distributed at child delivery
facility
Hepatitis B immunization
with immunoglobin
After the prophylaxis,
a bill for reimbursement is
written up and an
immunization booklet is
given to the pregnant
woman
Submit prophylaxis bills for
payment to the public
health center
Input prophylaxis bills for

payment submitted
Payment of immunization
costs
Second hepatitis B
immunization after
presentation of coupon
Information about
immunizations given to
guardian
Submit immunization
coupon at the public
health center
Submit immunizations
coupon
costs
Third hepatitis B
immunization after
presentation of coupon
Information about
immunizations given to
guardian
Submit immunization
coupon at the public
health center
Submit immunization
coupon
costs
9-15 months
after birth
Visit medical institution

for antigen-antibody
tests
Antigen-antibody test
and the results given
Information given to
guardian about examination
times and procedures
Antibody
nonresponder
Visit medical institution for

examination and
immunizations
Investigation management
Examination coupon and

immunization coupon
issued
Figure 6-4 | Flowchart of the Program to Prevent Perinatal Hepatitis B Infection
HBIG+
Vaccination
(3 times)
serologic
test
HBsAg(-)/anti-HBs(-)
revaccination
(1 times)
serologic
test
revaccination
(2 times)
serologic
test
nonresponder
HBsAg(+)/anti-HBs(+)
infected
HBsAg(-)/anti-HBs(+)
responder
responder
responder
HBsAg(+)/anti-HBs(-)
infected
infected
infected
1.5. Implications
In Korea, hepatitis B spread rapidly from the 1970s until 1995, when it was included
in the essential national immunizations. From that time on, we can see a drastic reduction
in the incidence of hepatitis B. This decline was not merely the result of an increase in
immunization coverage. Rather, it was the result of a multidimensional effort to actively
enlighten people through public health education and enhanced infection management with
a primary focus on the national government and public health centers. Consequently, the
number of pregnant women who tested positive for hepatitis B surface antigen has gradually
declined. Nevertheless, as 15,000 live births were exposed to perinatal hepatitis B every year,
an aggressive government policy was necessary. As a result, in 2002, a perinatal hepatitis
B prevention program was introduced. An estimated 96% of newborns who were targeted
were registered and received health care. Due to the aggressive participation of medical
facilities, the program was very successful. In addition, for better program management,
a computerized immunization program was developed. Through this program, institutions
ranging from the central government to public health centers and private medical institutions
can verify individuals in the program and manage their medical histories. This has proved
to be a very important strategy in the hepatitis B perinatal infection prevention program.
Through this program, the accessibility of immunizations for newborn infants exposed to
hepatitis B infection was greatly increased. It also cut cases of perinatal infections by more
than 95%.
2. Measles
2.1. Background
In the past, measles was common among children, causing many deaths among the young
population. In 1965, the measles vaccination was introduced in Korea and consequently
the number of measles cases slowly declined. In 1983, measles was included in the list
of national essential immunizations. Since then, small measles epidemics have occurred
repeatedly every 4-6 years and in 1994, a pandemic occurred. Both situations caused panics
in the general public. In 2000, 71.9 cases were identified per 100,000 persons and in 2001,
a total of 55,000 measles patients were reported. Two deaths due to measles occurred in
2000 and 5 deaths in 2001. Due to these events, the Korea Centers for Disease Control and
Prevention switched its strategy from managing measles to fighting the disease. This focused
national attention on the problem and as a result, the measles epidemics were brought to
a halt. Through an enhanced measles monitoring system, the number of occurrences of
measles was analyzed and now a level of 0.12 persons are infected with measles per million
persons [Figure 6-5].
Figure 6-5 | Measles Incidences per Year (1963-2000)
80
Incidence/100,000
Introduction of
measles vaccine
Introduction of
MMR vaccine
2nd MMR
immunizations
doses begin
(for children
aged 4-6 years)
Mandatory
MMR
immunizations
begin
60
40
20
0
1963 65
70
75
80
85
90
95
2000
Year
Source: C
enter for Disease Control and Prevention (2006), White Paper on a five-year national campaign against
measles, Center for Disease Control and Prevention, p.3 (in Korean)
2.2. Program Timeline

2000: Immunization program planned during the height of a measles pandemic
Project to survey national measles immunity
Establishment of a 5 year national plan to eradicate measles
Measles immunizations of children and those with no antibodies
2001: Procurement of MR vaccines for immediate measles immunization
Memorandum of understanding between UNICEF and the MR vaccine suppliers
Mass measles immunization catch-up program (for 6 weeks)
Implementation of project for follow-up doses of measles immunizations for
school children
2002-2005: Maintaining a program to check measles immunizations, measles eradication,
and program evaluation and monitoring
2006: Declaration of national measles eradication
2.3. Program Implementation and Execution

2.3.1. History of Measles Immunization with MMR Vaccines
During the measles outbreak from 2000 to 2001, basic immunization coverage according
to the ages of the patients who had a measles MMR vaccine was as follows: among patients
between one and three years, 34.9% had been immunized. In particular, 21.2% of children
above age one had been immunized, and 12.5-27.6% of children aged 12-15 months had
been immunized. This was relatively lower than the immunization rate for children older
than 17 months, which was 29.7%- 51.2% [Figure 6-6]. In the case of the patients between
12 and 15 months, it was usually verified that the individuals had not received basic
immunizations. The immunization coverage for measles patients from four to six years of
age was 72.1%. There was no special difference in the immunization coverage for measles
patients seven to fifteen years old, which was 72.9%-79.0%. Through these numbers, we
can see that individuals over three years of age became infected with measles even after
being immunized.
Figure 6-6 | Status of Measles Immunization History by Age
Reported number of children immunized
3,500
2dose
1dose
0dose
3,000
2,500
2,000
1,500
1,000
500
0
10
11
12
13
14
15
16
17
18 >19
Age (years)
Source: C
2.3.2. R
esults of a Study on Elementary and Middle School Immunization
Coverage Rate
In addition to routine immunization targets, the measles susceptibility level per age
was identified for school age children aged seven and older. Investigation on the measles
immunization coverage and serological immune investigations were performed in order
to select the ages that required immediate measles immunizations. The government
conducted random sampling in the public health centers in all cities and provinces by
asimple random sampling method -- selecting one individual out of a thousand between
the ages of 7 to 18 years. Then theyrandomly selected one student from everyelementary,
middle, and high school of the city or town. Finally, they selected 283 students for
approximately every 23,000 students ofelementary, middle,andhighschool. The survey
questionnaire on immunization history was filled out directly by the parents. According to
the results of this study, 86.2% of all elementary students had received the first immunization,
but only 37.7% had received the second immunization <Table 6-3>.
Among the age groups targeted for immediate immunizations (the Catch-Up Campaign),
considering the recent prevalence in measles and the susceptibility rate, individuals who
were fully susceptible to the disease accounted for 82.4% of the target group whereas the
percentage of students from the first grade in elementary school to the third year in middle
school who tested positive for antibodies fell just short of 95%.
Table 6-3 | Survey Results of Elementary and Middle School Students

(Unit: people, %)
Entire Immunization Course

Total number of
students targeted
Number of students
who had the first
immunization (%)
Number of students
who had the second
immunization (%)
1,571
1,368(87.1)
682(43.4)
1,631
1,439(88.2)
600(36.8)
1,599
1,391(87.0)
527(33.0)
1,604
1,366(85.2)
1,583
1,341(84.7)
1,507
1,277(84.7)
Total
9,495
8,182(86.2)
1,809(37.7)
1,631
1,322(81.1)
1,507
1,205(80.0)
1,399
1,111(79.4)
Total
4,537
3,638(80.2)
Grand total
14,032
11,820(84.2)
1,809(37.7)
School year
Elementary school
Middle school
Source: C
2.3.3. Plan for the Eradication of Measles

Until 2005 in order to eradicate measles in Korea, children between 12 and 15 months
were immunized with the first dose of measles vaccine and children between 4 and 6
years were immunized with a second dose so that the total immunization coverage was
maintained at 95% of the young population. In addition, 5.8 million children from the ages
of 8 to 16 years of age were administered immediate immunizations. They also ensured
the eradication of the indigenous endemic by strengthening the surveillance system of
laboratories and monitoring measles patients [Figure 6-7].
Important parts of the eradication history are as follows. First, the Catch-Up Measles
Immunization Campaign was implemented to improve collective immunity and to raise
the level of protection against measles propagation by temporarily targeting groups that are
susceptible to measles. Second, the Keep-up Immunization Campaign was implemented
to maintain an immunization coverage rate of 95% for children ages four to six. Twelve
to fifteen months after the first immunization, a second immunization was given. This
was verified by checking the computerized immunization records of each individuals
immunization history before the students entered elementary school. Finally, for those who
contracted measles, the source of the infection was tracked down and simultaneously, a
surveillance system of laboratories and patients medical histories was set up so that the
epidemic could be stopped in its early stages.
Figure 6-7 | Staged Goals and Programs for Measles Eradication
Survey projects
Temporary
measles
immunization
Program for
checking
immunization
history of
elementary
school entrants
2000
2001
2001-2005
2001-2005
2006
Immunization
expanded in a
range of settings,
cost effectiveness
analysis
Coverage for
second
immunization
improved
40% 95%
Maintain a
immunization
coverage
rate of 95%
Monitoring
inflow and
preventing
foreign and
emerging
measles viruses
No indigenous
virus
Monitoring
projects and
evaluation
Declaration of
eradication
Source: C
2.3.4. M
easles Patients that Contracted the Disease after the Immediate
Immunizations
The total number of measles patients from January 2001 to July of that year was l 21,865.
(In January, 7,398, in February 2,774, in March 2,831, in April 4,062, in May 3,388, in June
1,257, and in July till the 28th, 182.) Every month there were thousands of new patients.
However, due to the immediate measles immunizations and the mandatory submission and
confirmation of second immunizations implemented in March 2001, the overall measles
immunization coverage was dramatically improved and diagnosed cases were significantly
reduced. As a result, the 2000-2001 measles outbreak which had claimed more than 55,000
people was under control by August [Figure 6-8].
Figure 6-8 | Relationship between Incidence of Measles and

Measles Immunization Coverage
Immunization coverage rate
Number of measles patients
200
100
180
90
160
80
140
70
120
60
100
50
80
40
60
30
40
20
20
10
5/1
5/5
5/9
5/13 5/17 5/21 5/25 5/29 6/2
6/6
6/10 6/14 6/18 6/22 6/26 6/30
7/4
7/8 7/12 7/16 7/20 7/24 7/28
Onset of the measles
Source: C
2.4. Implications
The 5 Year National Measles Elimination Project set up as a countermeasure for the
measles epidemic in 2000-2001, is a good example of successfully eradicating measles at
the national scale. Out of the 55,696 patients diagnosed with measles, there were 7 deaths in
this national outbreak. In response, a national survey on the measles immunization coverage
and the collective immunity to measles was immediately conducted. In conclusion, the
major problems were narrowed down as following: the outbreak stemmed from individuals
failing to acquire immunity after the first immunization and the poor rate of second
immunizations. In order to solve this, a program was implemented in 2001 to make sure that
school children had received the second immunization. In addition, 5.8 million school age
children were given immediate measles immunizations. Immediate mass immunizations
were implemented nationally focusing on 244 public health centers in 16 metropolitan
areas, and doctors, nurses, and other reporting personnel mobilized into 11,940 teams for
this. As a result, the immunization coverage rate was raised to 97.4% through immediate
immunizations. That is, the incidences of the measles, which had been on the rise till
the middle of 2001, had drastically reduced. From 2002 to 2006, less than one out of a
population of a million was infected with measles. And for the first time on November 7,
2006 the World Health Organizations Western Pacific Region Office declared that measles
had been eradicated in Korea.
In case of a death after an immunization or occurrences of other adverse side effects, a

quick and careful epidemiological survey was conducted to ascertain the relevance of the
vaccine to the death or severe disability. This was released to the public to instill trust in the
safety of the vaccine. In this way the entire program could be reliably implemented.
Finally, the national measles eradication program, public health centers, regional medical
associations, and the Department of Education efficiently implemented various parts of
the immunization program despite the lack of inter-agency coordination and cooperation
due to disagreements with the governments immunization policy. In a short period of
time, immediate measles immunization could be implemented effectively due to the active
cooperation between the Immunization Expert Committees, private citizen organizations,
practicing physicians, and other related organizations. Thanks to such combined effort,
measles was successfully and nationally eradicated in 2006.
3. Pandemic Influenza A (H1N1)

3.1. Background
After April 26, 2009, when the first case of H1N1 flu was diagnosed in the United States,
H1N1 flu has spread rapidly throughout the world. In Korea, the first patient was diagnosed
on March 2, 2009. In mid-August, the influenza-like illnesses (ILI) exceeded the standard
of 2.67 people per population of a thousand. In the beginning of October, it spread rapidly
at schools and by the end of the month, it had reached its peak of 45 people per thousand
having contracted the disease (CDC, 2010). [Figure 6-9] After December, the number of
patients decreased. A total of 763,759 patients were diagnosed with the disease in the first
three weeks of 2010. In addition, the first deaths were reported in August, which the total
number due to the influenza was 270 (Lee, 2011).
The H1N1 flu was a kind of virus that humankind had not experienced before and was
expected to spread rapidly. When the World Health Organization (WHO) realized that the
H1N1 flu was an inter-continental pandemic, the organization declared it a pandemic on
June 11, 2009. However, as the actual occurrences of the flu had only been confirmed in
a subset of the patients, the number of aggregate patients were not included as of July 6.
Based on sources abroad, the most obvious demographic characteristics of the pandemic
appear to be patients mostly children or young adults in the age range from 5 to 24 years. In
approximately 80% of the cases, the individuals were younger than 30 years old. Yet, there
was no difference in the susceptibility by sex.
Fractions representing the share of patients nationally

who exhibited influenza-like symptoms
Figure 6-9 | Progress and Policy Regarding 2009-2010 H1N1 Influenza
09~10
08~09
Accessibility of anti-viral
medications expanded to
all pharmacies (10/30)
Immunizations
(10/27)
Full-scale operation at
medical institutions serving
as hubs (8/21)
Containment policy
(Quarantine, patient
isolation) (4/28)
Target of antiviral
medications
expanded (9/1)
Minimization of injury
(Surveillance, Treatment)
(7/29)
10
11
12
Source: C
enter for Disease Control and Prevention (2010), White Paper on Responses to New Strains of Influenza
in 2009-2010, Center for Disease Control and Prevention, p. 20 (in Korean)
The large scale of H1N1 flu incidences that occurred from the autumn of 2009 to the
summer of 2010 led to social turmoil, shrinking of socioeconomic activities, and inadequacy
of the crisis response system. During that time, the country relied on flu vaccine supplies
from overseas, so it was very difficult to temporarily raise collective immunity in response
to the large scale danger. However, through these experiences, the institutional deficiencies
were improved, and there was an opportunity to mend the system.
Immunizations were the primary means of preventing the flu epidemic. Through
immunizations, the propagation of the flu was blocked. There was also a reduction in
the severity of the illness, morbidity, and period of infection (through the reduction
of complications, hospitalizations, and deaths). By shortening the time of the spread of
a virus, the general pervasiveness of the flu can also be reduced. In particular, the goals
of the immunization policy were as follows: first, to offer safe and effective vaccines as
quickly as possible; second, to ascertain which individuals should have priority in receiving
immunizations so that the spread of the pandemic could be effectively blocked and the
mortality rate be lowered; third, to come up with ways to offer immunizations and assign
vaccines as quickly as possible to those individuals who were targets of the immunization
policy; and fourth, to continually monitor and evaluate any adverse reactions or side-effects
of the immunization.
3.2. Program Implementation and System

3.2.1. Principles and Implementation System
H1N1 flu was managed based on the basic principles that the propagation of an epidemic
through a community can be blocked by improving the immunization coverage of the
community. Immunizations were given according to the following principles: first, when
immunizations and preliminary medical examinations were voluntarily agreed; second,
when immunization records were managed through the Immunization Registry Information
System (IRIS); and third, when the patient was monitored to check if there were any negative
side effects after the immunization. The system was implemented by the Central Influenza
Task Force in the Department of Health and Human Services and the responsibility for
the public health was divided among the private medical institutions, the schools, and the
public health centers [Figure 6-10].
Figure 6-10 | Implementation of the H1N1Influenza Immunization Program
Central Influenza Task Force
Cooperation
Ministry of Health Welfare
Immunization Review Committee

Immunization Injury Compensation Panel
Advisory
Project Team for H1N1 Immunizations
Coope- Centers for Disease Control and Prevention

ration
Korean Medical Association

Korean Hospital Association
Korean Medical Practitioners Association
Cooperation
Ministry of the Strategy and Finance

Ministry of Education, Science and Technology
Ministry of Justice
Ministry of National Defense
Ministry of Public Administration and Security
Ministry for Food, Agriculture, Forestry and Fisheries
Immunization program advisory groups
School Immunization program advisory groups
Metropolitan cityprovince
Contact
Immunizations at
medical institution
School immunizations
Immunizations at
Infants, pregnant women,

those who chronically ill
Elementary, middle and

high school students
Elderly, those who work at

social welfare facilities
Source: C
enter for Disease Control and Prevention (2009), Guidelines for an Immunization Campaign against
New Strains of Influenza A (H1N1), Center for Disease Control and Prevention, p.3 (in Korean)
3.2.2. Targets of Priority Immunizations

To solve the insufficient supply of vaccine and to prevent the temporary increase of
persons that require immunizations, the Immunization Expert Committee decided to give
priority to individuals who were at higher risk of infection and those who were in critical
condition.
Table 6-4 | Priority Targets for the H1N1 Influenza Vaccine
Categories
Individuals given priority for immunizations
Medical personnel
(800,000)
Workers in medical institutions

Epidemic prevention workers, first responders, those engaged in
animal husbandry (such as pig breeding), 1199 responders and
police
Vulnerable
(8,200,000)
Pregnant women, children (6 months - 6 years, children aged 6

who were too young to go to school)
Those over 65 and healthy
Chronically ill patients (including those 65 and older)
Postpartum care center workers
Infant day care workers
Students (7,500,000)
Elementary schoolmiddle schoolhigh school students, head

nurses
Military (660,000)
Soldiers
Source: C
enters for Disease Control and Prevention (2009), Guidelines for an Immunization Campaign against
New Strains of Influenza A (H1N1), Centers for Disease Control and Prevention, p.4 (in Korean)
From a holistic perspective, the lack of vaccines was not serious. However, because
of the limited supply of the vaccines and the sudden increase of individuals that needed
immunization, there was a mismatch of vaccines in supply and demand. In order to mitigate
the temporary shortage in vaccines, the Immunization Expert Committee decided which
individuals would have priority for the H1N1 flu immunizations so that the immunizations
would have the most effect in blocking the spread of the disease <Table 6-4>. The government
did this by securing sufficient vaccines so that those who needed an immunization could
all receive it. Because vaccine production and supply was done sequentially until the end
of 2009, health care workers and epidemic prevention agents, soldiers, elementary school
students, middle school students, high school students, children, and pregnant woman were
immunized in that order. From January 2010, the elderly and those suffering from chronic
illnesses were immunized [Figure 6-11].
9. This is similar to 911 services in some other countries.

Figure 6-11 | Priorities for H1N1 Influenza Immunizations by Time Period
2009
Category
October
2010
November December
January
February
Health care workers,

epidemic prevention workers, soldiers
Elementary, middle and high school students
Children aged 6 months to 6 years, pregnant women
Elderly, those chronically ill
Source: C
The government could make sure that individuals who had received priority for
immunizations were all able to be immunized by the deadline. This was possible through
diversifying the providers of the immunization services and specifying the primary location
for those who were targeted for immunizations <Table 6-5>.
Table 6-5 | Methods of Providing H1N1 Influenza Immunization Service according
to the Individuals Targeted by the Program
Categories
Immunization location
Immunization costs
Infants, pregnant
women,
those with chronic
illnesses
Commissioned medical
institutions
Cost for immunizations at private

medical institutions are borne by the
individual
* Vaccine supplied at no cost
Elementary,
middle and high
school students
School and commissioned

School immunizations at no cost

* If private medical institutions were
used, cost is borne by the individual
Healthy and older

than 65
Public health center and

Public health center immunizations at

no cost
* If private medical institutions were
used, cost is borne by the individual
Source: C
3.2.3. H1N1 Influenza Immunization Management System

In 2009, the H1N1 flu immunization registry management system was developed
and implemented. The system included immunization records (including personal
information along with individual immunization records), immunization statistic lookups,
adverse reactions that had been reported, vaccine supply management (vaccine request,
acknowledgement, surplus/waste), and information management for schools (school
immunization applicant status, whether students had been immunized or not). The system
for the H1N1 flu immunization management system could be accessed through the system
for health and diseases <Table 6-6>.
Table 6-6 | Major Features of the H1N1 Influenza Immunization
Management System
System configuration
Major features
Immunization
reservation
Immunization appointments directly or through a medical

institution
Immunization statistics
Reservation status management
Immunization records
registration/enrollment
Immunization records, registration, sending SMS

(text messaging)
Immunization statistics
query
H1N1 flu immunization history
Reports of adverse
reactions
Report adverse reactions
Management of vaccine
supply
Requests, approval, and management of vaccines
Management of school
information
Management of school immunizations, modify school

information
In order to offer immunizations to the general public, an immunization assistant website

was set up at (http://nip.cdc.go.kr). The general public or those who had been recommended
to get the H1N1 flu immunization could connect to the site, make an appointment for an
immunization, and be notified about their appointment by an SMS text message. On the
scheduled day, the medical institutions conducting the immunization would register the
immunization in the immunization records for that individual.
3.2.4. Management of H1N1 Influenza Vaccine Supply

Vaccines were kept in refrigerated vehicles to keep the supply cold. In the case of medical
institutions, they were supplied by the local public health center [Figure 6-12].
a. Vaccine Supply by Facility
1. Public health center: supplies for school immunizations or public health center
immunizations
2. Medical institutions: depending on the demand, vaccines were supplied through the
public health center
* When health care workers were immunized, base hospitals or general hospitals
received direct vaccine shipments. Other medical institutions received supplies
through their public health center.
Figure 6-12 | Supply System for the H1N1 Influenza Vaccine
Public health
center
Vaccine allocation
requested
Vaccine allocation
approved
Immunizations at
Implementation of
immunizations
Notice of delivery
Vaccine
supply
Vaccine supply
Implementation of
immunizations
Manufacturer
(Supplier)
Immunizations
demand notice
School
immunizations
Infants, pregnant women,

those chronically ill
Elementary, middle and

high school students
3.3. Program Implementation

From October 2009 to May 2010, approximately 14,750,000 dosages of vaccine were
used. This was 75.4% of the entire doses (18,890,000) that were originally planned. From
October to December 2009, health care workers, epidemic response personnel, and students
were scheduled for immunizations. Of those targeted, 64.4% received immunizations. From
January to March 2010, children from six months to six years old, pregnant women, elderly,
and those with chronic illnesses were targeted. Of those targeted, 39.9% were immunized.
All immunization records temporary immunization, immunization area, vaccine lot
number, and immunization username registration were managed from the H1N1 flu
immunization management system [Figure 6-13].
Figure 6-13 | Screenshot of the H1N1 Influenza Immunization Registry
Information System
3.4. Implications
Even before the outbreak of H1N1 flu in 2009, the influenza immunization coverage in
Korea was quite high. This is because the government predicted the outbreak even before it
started and continued to watch it as it unfolded. Those at high risk of contracting the disease
(such as the elderly and hospital workers) had seasonal influenza immunizations every year,
and the vaccines in public health centers were well stocked. Furthermore, the government
continued to monitor the situation, issue advisories, and educate the public about the flu.
The Immunization Registry Information System which had been already operating before
the outbreak of the flu epidemic, set up immunization appointments in advance. This system
targeted those who were at high risk and who met the vaccine supply capacity with gradual
immunization schedules. Computerized registration for the general public was available
at public health centers and medical institutions. Through the computerized system, the
sudden temporary lack of vaccines could be spotted at once. Accordingly, the problem of
having a large influx of citizens clamoring for immunizations could be prevented. Also, due
to the systems operation, immunization coverage was very high.
Sudden shortages of flu vaccine had occurred for many years, but Korea is ready to
produce vaccines now. So, when there is an outbreak of an epidemic, the government would
be ready. The government could smoothly facilitate the supply of vaccines and the H1N1 flu
pandemic could be adequately controlled.

Chapter 7
Strategies for Increasing Public Participation
1. Vaccination Week
2. Immunization Reference Website
3. Short Message Service (SMS) for Confirmation of
Immunization and Notification of Next Immunization
Schedules
4. Vaccination Training for Health Care Providers
Strategies for Increasing Public

Participation
1. Vaccination Week
1.1. Background
The last week of every April is Vaccination Week, enacted by the World Health
Organization (WHO). During this week, the importance of vaccination is promoted and the
attempts to eradicate diseases are reviewed. In addition, in order to improve the childrens
vaccination rate and further increase public awareness, the global society is cooperating
and working together. After Vaccination Week, initiated by the WHO, was first enacted
in the Pan-American Health Organization (PAHO) in 2002, it has been implemented in
the European Union (EU) since 2005, and the Eastern Mediterranean Regional Office
(EMRO) since 2010. This event has become a global campaign to evaluate the outcome of
immunization programs and to cooperate for the eradication of infectious diseases.
Vaccination Week was introduced in the Western Pacific Regional Office (WPRO)
in 2011. 31 countries10 including Hong Kong, Macao, and 29 countries of the Western
Pacific region such as Korea, Japan, and China, participated in this project. In particular,
the purposes of the Vaccination Week are the improvement of the vaccination rate,
the celebration of the outcome of the immunization program, the education of parents
and guardians on the importance of vaccination, and the increase of public and media
awareness. Korea has also established its own goals for Vaccination Week as follows:
10. The following countries (or regions) participated in the WHO Vaccination Week: Republic of (South)
Korea, American Samoa, Brunei, Cambodia, China (PRC), Cook Islands, Fiji, Polynesia, Guam, Japan,
Kiribati, Laos, Marshall Islands, Micronesia, Mongolia, Nauru, New Caledonia, New Zealand, Niue,
Northern Mariana Islands, Papua New Guinea, Philippines, Samoa, Solomon Islands, Tokelau Islands,
Tonga, Tuvalu, Vanuatu, Vietnam, Hong Kong, and Macao.
the increase of public awareness about vaccination, a united front against infectious
disease control among associated organizations, and the attainment of the core goals of
the national immunization program.

1.2.1. The First Vaccination Week
The first Vaccination Week held in Korea was April 24 - 30, 2011 and its slogan was
Vaccination for Tomorrow. The first Vaccination Week was proclaimed at the WHO
Western Pacific Regional Office in Manila on April 25, 2011. On this day, the government,
health care, and vaccination-related representatives such as the Korean Minister of Health
and Welfare and the director of the Korea Centers for Disease Control and Prevention
participated in the official proclamation. In addition, a publicity campaign to inform the
public about the importance of vaccination was carried out through diverse media outlets
including newspapers and broadcasting stations. This event included the screening of a
documentary on the National Immunization Program describing the history and the outcomes
of the Korean immunization program, showing appreciation to those who have significantly
contributed to the success of this project so far, naming an honorary ambassador for the
project, commemorating the significance of vaccination for a healthy tomorrow through
performances such as sand art, and inviting guest speakers to lectures on the history and
significance of vaccination.
1.2.2. The Second Vaccination Week

The second Vaccination Week was held in April 21 - 28, 2012. Its slogan was A Healthy
Future for Your Family. For the commemoration event, a famous childrens program TV
Kindergarten: Lets Come Together . . . Thats Right! and a musical puppet show about
vaccination drew the attention of children aged 4 through 12. They were the main targets for
follow-up vaccinations along with their parents and guardians. In addition, various events
and campaigns such as the naming of an honorary ambassador for this program and an
exhibition of life-size optical illusions were held.
Chapter 7. Strategies for Increasing Public Participation 131
1.3. Suggestions
It is not easy to draw conclusions about the Vaccination Week yet because Korea has
had only limited experience with this program. However, it is expected to be a worthwhile
strategy in raising public awareness of the importance of vaccination and reminding parents
and guardians of the immunizations that could be missed on the vaccination schedule for
children.
2. Immunization Reference Website

2.1. Background
The Korea Centers for Disease Control and Prevention has provided an immunization
reference website <http://nip.cdc.go.kr> for convenient access to immunization information.
This website provides services such as immunization information, the immunization
schedule, Q&A, the National Vaccine Injury Compensation Program (VICP), information
on immunization-related programs, a reporting system for side effects after vaccination, and
issuance of immunization records. For users convenience, both PC and mobile versions are
supported.

The immunization reference website was developed in 2002. In 2004, a self-reporting
system about vaccination side effects for parents and guardians was available and a
retrieval system for technical immunization information was established in 2007. Parents
and guardians could access their childrens immunization records anytime after signing up
and undergoing real-name authentication <Table 7-1, 2>. From 2011, a mobile application
service has been available, which total number of downloads was 113,738, including 80,275
for Android users and 33,463 for iPhone users.
Table 7-1 | Number of Members Registered in the Immunization Reference Website
(Unit: persons)
Year
2003
Number of
members
1,699
2004
2005
2006
2007
2008
2009
11,712 16,370 13,389 23,977 32,019 108,076
2010
2011
74,009
226,560
Table 7-2 | Number of Visits to the Immunization Reference Website

(Unit: persons)
Classification
Click rate
(number of visits)
2005
2006
2007
2008
2009
38,944 37,750 63,160 91,879 259,572
2010
2011
216,987
514,971
3. Short Message Service (SMS) for Confirmation of

Immunization and Notification of Next Immunization
Schedules
3.1. Background
As private clinics started to actively participate in the national immunization program, the
registration rate of personal immunization records has increased in the Immunization Registry
Information System (IRIS). Hence, most immunization records are now computerized.
Yet, the information of where and how the data has been collected and computerized has
become an important political issue. Based on these immunization records for children, the
KCDC provides Short Message Service (SMS) about immunization information and the
next scheduled immunization date through mobile phones.

3.2.1. Immunization Confirmation Service
An immunization confirmation service was established in March 2009. This service
applies to immunization cases in medical institutions that participate in the medical expense
reimbursement system. For instance, if children aged 0 through 12 have received their core
required immunizations including BCG, Hepatitis B, DTaP, Td, IPV, MMR, varicella,
Japanese encephalitis, DTaP-IPV, and Tdap, the next day, parents and guardians will receive
a confirmation of the childrens immunization information as follows: Your child received
[vaccine name] at the [clinic name] on [month and date].
3.2.2. SMS Immunization Reminder Service

Since December 2010, KCDC has provided a recall SMS for children who have been
registered in the immunization registry system and have agreed to receive SMS text
messages. If the immunization record for children aged 0 through 12 has been updated in
the registry system, the next immunization date is automatically calculated and the parent
or guardian is informed by an SMS text message as follows: The next immunization date
for [childs name] is coming up. Please check your childs immunization history at http://
nip.cdc.go.kr.
4. Vaccination Training for Health Care Providers

4.1. Background
The public health conditions in South Korea in the 1960s and 70s were extremely poor due
to the spread of infectious diseases and the poor public health infrastructure. The number of
health care providers was far from meeting the demand. Moreover, the supply of physicians,
nurses, and even nurse aids was also terribly insufficient in public health centers and their
branches. Thus, the health personnel of public health center branches in towns (eup) and
sub-counties (myeon) had only been trained on the skills and knowledge of vaccinations by
physicians of the public health centers, appointed branch office directors, and physicians
who could practice in only a limited area. In addition, most health personnel in the towns
(eup) and sub-counties (myeon) were unlicensed middle or high school graduates; thus, it
would be difficult to categorize them as public health experts. Accordingly, at that time,
systematic immunization training for physicians and health personnel was not realistic.
However, as socioeconomic conditions in Korea have improved, physicians and health
personnel in public health centers were also trained by the National Institutes of Health.
Furthermore, physicians in private clinics have been educated by academic societies.
Meanwhile, public health centers had no motivation to take leadership over private
clinics in immunization projects. When private clinics were first allowed to participate in
the National Immunization Program in 2009, physicians and specialists in private clinics
were systematically provided with education by the government. In other words, with the
establishment of the government policy for the participation of private clinics, a cooperation
system between the public health centers and the private clinics was also established. If
a private clinic had not received training for vaccination, it could not participate in the
National Immunization Program (reimbursement system).

4.2.1. Online Training for Medical Institutions
In the beginning of 2009, classroom-based training was performed for those in
medical institutions involved in the required immunization support program (NIP), the
reimbursement program for private clinics, and the H1N1 prevention program. However,
classroom training has now been replaced with online training in order to increase the
accessibility to trainees.
Online education for medical institutions that provide immunization services include
a basic training course and a refresher training course. Online training courses are being
administered by the KCDC training system at http://edu.cdc.go.kr.
It was recommended that the basic training course be completed by every immunizationrelated health care provider including physicians, nurses, and nurse aids. In particular, this
course must be completed by more than one physician before the medical institution makes
a contract to participate in the medical billing reimbursement system. A total of 7 courses are
provided. In addition, the refresher training course should be completed by every medical
institution with a vaccination contract at least once a year <Table 7-3>.
Table 7-3 | Online Training Courses for Medical Institutions in 2012
Classification
Basic training course title
Refresher training course title
1st class
Introduction to the National

Immunization Program (NIP)
Introduction to NIP
2nd class
How to use the Immunization

Registry Information System (IRIS)
Standards and methods for

vaccination (I)
3rd class
How to use the medical expense

reimbursement system

vaccination (II)
4th class

vaccination (I)
5th class

vaccination (II)
6th class
Adverse reactions after vaccination
7th class
Handling and storage of vaccines
4.2.2. Offline Training for Health Care Providers

Special offline training courses have been conducted for various participants including
vaccination staff, staff of the prevention program for perinatal transmission of hepatitis
B, influenza vaccination staff, vaccination physicians in cities/provinces/and public health
centers, and call center (129) representatives in the Ministry of Health and Welfare (MOHW)
<Table 7-4>.
Table 7-4 | Special Offline Vaccination Training Courses for Health Care Providers
(Unit: days, persons)
Training Course
Title
Special training
for vaccination
staff in cities,
provinces, and
public health
centers
Training for staff
of prevention
program
for vertical
transmission of
hepatitis B in
cities, provinces,
and public health
centers
Training for
influenza
vaccination
staff in cities,
provinces, and
public health
centers
Special training
for vaccination
physicians in
cities, provinces,
and public health
centers
2009
Days for
training
2010
Number of
attendees
2011
Days for
training
Number of
attendees
Days for
training
Number of
attendees
One day
343 people
One day
194 people
One day
384 people
One day
338 people
One day
333 people
One day
290 people
One day
270 people
One day
448 people
Two days
387 people
Two days
378 people
one day
187 people
one day
182 people
Training Course
Title
2009
2010
2011
Days for
training
Number of
attendees
Days for
training
Number of
attendees
Days for
training
Number of
attendees
Special training
for H1NI
vaccination
staff in cities,
provinces, and
public health
centers
One day
409 people
Training for call

center (129)
representatives
of MOHW
One day
One day
One day
42 people
21 people
100 people
3 days
3 days
27 people
27 people
Training for
vaccination
consultants

Chapter 8
Monitoring of Immunization Outcomes
1. Korean National Immunization Survey

2. Factors Affecting the Immunization Rate
Monitoring of Immunization
Outcomes
1. Korean National Immunization Survey

1.1. Introduction
The immunization rate is a very important indicator that shows the outcomes of
vaccination. With this rate, the vaccination level can be monitored, preventable infectious
diseases can be brought toward the eradication level, and immunization rates can be
compared among different countries. Thus, each country has developed various survey
methods to determine the immunization rate. In addition, several studies are focusing on
the frequency needed for surveys and the data sources.
In several countries other than Korea, a survey is conducted once a year. Survey methods
include telephone surveys (CDC, 2010), ground mail surveys (Public Health Agency of
Canada, 2006), household interviews (World Development Report, 1993; WHO, 1993;
Ministry of Health, 2007), and computerized data surveys (Immunization Advisory Centre,
2010; The NHS Information Centre, 2010). Target age groups are also diverse.
Since 1982, the Korean Immunization Survey has been conducted as part of the National
Survey on Fertility, Family Health and Welfare in Korea. This is conducted once every three
years; however, the survey design has been inadequate and the survey itself has not been
performed every year. Furthermore, despite the fact that household interviews in specific
areas (Shin, et al., 2005) and telephone/household surveys at the national scale (Park, et
al., 2011; Park, et al., 2009) were conducted, these should be characterized as pilot studies
that are used to evaluate various possible samples and their accuracies rather than official
national statistics.
Even though the immunization rates in Korea have been estimated using administrative
and vaccine supply data for convenience, the reliability of the data and the accuracy of
statistics were inadequate. Since 2002, the Immunization Registry Information System
(IRIS) has been administered on the internet; however, the IRIS system is not for every
vaccine from all immunization providers, but only from voluntary providers. Thus, accurate
statistics on the immunization rate remain limited (Lee, et al., 2009; Lee, et al., 2012).
Accordingly, since 2011, the immunization rates have been determined by a nationally
standardized survey method which is designed to calculate the immunization rates at the
national, metropolitan, and province levels.
1.2. Introduction to the Survey

1.2.1. Subjects
Following the prescribed schedules for each immunization, the subjects of the survey are
three-year-old children, who should have completed the core required immunizations, and
seven-year-old children, who are at the age of having all of their follow-up immunizations
completed. As indicated by required residential registration at the appropriate local
government office, the target populations are three- and seven-year-old children whose
immunization records have been registered in KCDC IRIS at least once. IRIS is the
computerized system that was implemented in 2002. Through this system, subjects
information can be more accessible than from other data sources as variables related to
immunization are included and consent for official data collection has already been given in
advance. Moreover, the data from IRIS is valuable for determining the immunization rates
because of the high data accuracy and registration rate.
1.2.2. Sampling Methods

The samples are distributed from each of the 16 metropolitan cities and provinces. The
samples in the provinces including cities and counties, that is, urban and rural areas, are
distributed by the population rates between the cities and counties. The same number of
minimum sampling was selected only as an original sample. It was designed so that the
substitute sample was selected with the up and down order of the substitute sample.
Chapter 8. Monitoring of Immunization Outcomes 141
1.2.3. Data Collection

a. Three-Year-Old Children
Vaccination lists for the survey
- National core required immunizations (National Immunization Program; NIP):
tuberculosis vaccine (BCG; intradermal injection), hepatitis B three doses, diphtheria,
tetanus and acellular pertussis vaccine (DTaP) four doses, inactivated polio vaccine
(IPV) one dose, measles, mumps, and rubella (MMR) one dose, varicella (Var) one
dose, and Japanese encephalitis (JEV; inactivated vaccine) three doses
Immunization records (for the lists mentioned above), immunization dates, type of
immunization clinic, and names/areas of immunization medical institutions
Factors affecting immunization rates
b. Seven-Year-Old Children
Vaccination lists for the survey
- National core required immunizations (National Immunization Program; NIP): BCG
(intradermal injection), hepatitis B three doses, DTaP five doses, IPV four doses,
MMR two doses, varicella one dose, and JEV (inactivated vaccine) four doses
Immunization records (for the lists mentioned above), immunization dates, type of
immunization clinic, and names/areas of immunization medical institutions
Factors affecting the immunization rate
1.2.4. Methods
A computer-aided telephone interview (CATI) is used and the source of data is personal
immunization records. Only the vaccination lists in these immunization records are included
in the survey.
1.2.5. Calculation of Weighted Values

The immunization rate is calculated after being treated with a weighted value so that
the result of the sample survey is representative. For the estimated immunization rate of
the survey population by nation/metropolitan city/and province, the variables used for
correction are residential area (urban or rural) and sex.
1.2.6. Accuracy Validation

Immunizations are documented in medical records, IRIS, and personal immunization
records. Technically, these three sets of records should correspond; however, mismatches
occur for various reasons. There are advantages of using personal immunization records
such as its convenience, the acquisition of consent, and the completeness of the data. On
the other hand, it also has various disadvantages. Thus, the validation accuracy should be
considered to guarantee the accuracy of the data. For this, using the data from personal
immunization records collected through CATI, the following data sources are reviewed:
1) IRIS, 2) medical records, and 3) a copy of the content from the personal immunization
records.
1.3. Survey Results

1.3.1. NIP Immunization Rates (from the core required immunization
list) and Schedule
The rates of immunization based on the list and schedule of the core required immunizations
in 2011 were as follows: BCG, 98.8%; the first dose hepatitis B vaccination, 99.0%; the
second dose hepatitis B vaccination, 99.3%; the third dose hepatitis B vaccination, 98.7%;
the first dose DTaP vaccination, 99.6%; the second dose DTaP vaccination, 99.5%; the third
dose DTaP vaccination, 99.1%; the fourth dose DTaP vaccination, 93.5%; the first dose
polio vaccination, 99.4%; the first dose MMR vaccination, 99.2%; varicella, 97.7%; the first
dose JEV vaccination, 97.9%; the second dose JEV vaccination, 95.9%; and the third dose
JEV vaccination, 90.7%. The first dose DTaP vaccination showed the highest immunization
rate, at 99.6%, whereas the lowest rate was 90.7% for the third JEV vaccination <Table
8-1>.
Table 8-1 | Immunization Rates by Schedule for the Core Required Immunization
List in 2011 (Three-year-old Children)
Cities
Counties
Nation
Time of
administration
(95%CI)
(95%CI)
(95%CI)
One dose
Within 4 weeks
98.8
(0.4)
99.2
(0.6)
98.8
(0.4)
First dose
0 months
98.9
(0.4)
99.1
(0.6)
99.0
(0.4)
Second
dose
One month
99.3
(0.4)
99.5
(0.6)
99.3
(0.4)
Third dose
Six months
98.7
(0.4)
98.3
(1.0)
98.7
(0.4)
First dose
Two months
99.6
(0.2)
99.6
(0.4)
99.6
(0.2)
Second
dose
Four months
99.5
(0.2)
99.3
(0.6)
99.5
(0.2)
Third dose
Six months
99.1
(0.4)
98.7
(0.8)
99.1
(0.4)
Fourth
dose
15-18 months
93.5
(1.0)
93.0
(2.0)
93.5
(0.8)
First dose
Two months
99.4
(0.2)
99.4
(0.6)
99.4
(0.2)
Second
dose
Four months
99.3
(0.2)
98.2
(2.0)
99.3
(0.2)
Third dose
Six months
98.5
(0.4)
97.3
(2.0)
98.4
(0.4)
MMR
One dose
12-15 months
99.2
(0.4)
99.2
(0.6)
99.2
(0.4)
Varicella
One dose
12-15 months
97.7
(0.6)
97.8
(1.2)
97.7
(0.6)
First dose
12-36 months
97.9
(0.6)
98.1
(1.0)
97.9
(0.6)
Second
dose
12-36 months
95.9
(0.8)
95.8
(1.6)
95.9
(0.6)
Third dose
12-36 months
90.7
(1.6)
91.6
(2.9)
90.7
(1.4)
Vaccination
BCG
Hepatitis
B
DTaP
Polio
JEV
1.3.2. Rate of Complete Immunization from the Core Required

Immunization List (NIP)
Completed immunization rates for the vaccinations on the NIP list are as follows: 98.2%
for Hepatitis B three doses, 93.2% for DTaP four doses, 98.4% for polio three doses, and
61.4% for JEV three (or two) doses. Completed immunization rate by series are as follows:
3:3:3:1 series, 91.9%; 4:3:1 series, 95.9%; 4:3:1:3:1 series, 90.4%; 4:3:1:3:1:1 series,
88.7%; and 4:3:1:3:1:1:3 series, 56.3% <Table 8-2>.
Table 8-2 | Completed NIP Immunization Rates in 2011 (Three-year-old Children)

Type of vaccine
Cities
Counties
Nation
(95%CI)
(95%CI)
(95%CI)
98.2
(0.4)
97.5
(1.2)
98.2
(0.4)
Three doses
99.0
(0.4)
98.7
(0.8)
99.0
(0.3)
Four doses
93.2
(1.0)
92.6
(2.0)
93.2
(0.8)
Three doses
98.5
(0.4)
97.0
(2.0)
98.4
(0.4)
Three (or two) doses
61.8
(1.8)
56.1
(3.9)
61.4
(1.6)
92.1
(1.0)
90.1
(2.7)
91.9
(1.0)
96.1
(0.6)
93.4
(2.4)
95.9
(0.6)
90.6
(1.0)
88.0
(2.9)
90.4
(1.0)
88.8
(1.2)
86.7
(2.9)
88.7
(1.0)
56.8
(1.8)
50.3
(4.0)
56.3
(1.7)
Hepatitis B
Three doses
DTaP
Polio
JEV
Series
3:3:3:11)
4:3:12)
4:3:1:3:1
3)
4:3:1:3:1:1
4)
4:3:1:3:1:1:3
5)
1) Series 3:3:3:1: DTaP three doses, polio three doses, hepatitis B three doses, and BCG one dose
2) Series 4:3:1: DTaP four doses, polio three doses, and MMR one dose
3) Series 4:3:1:3:1: DTaP four doses, polio three doses, MMR one dose, hepatitis B three doses, and BCG one dose
4) Series 4:3:1:3:1:1; DTaP four doses, polio three doses, MMR one dose, hepatitis B three doses, BCG one dose,
and varicella one dose
5) Series 4:3:1:3:1:1:3: DTaP four doses, polio three doses, MMR one dose, hepatitis B three doses, BCG one dose,
varicella one dose, and JEV three (or two) doses
1.4. Implications
The Korea immunization rate survey has been performed as a part of the Maternal Child
Health Services survey. Thus, the immunization survey could not be designed for measuring
accurate immunization rates. Besides, these intermittent immunization surveys were not
meant to be official national data. It was not until 2011 that an official immunization
survey was launched. This survey has been conducted with a standardized survey method
developed by the KCDC.
The 2011 survey data reveals high immunization rates because of parents keen interest
in immunization, free immunization services at public health centers, parents high trust
for the immunization services at public health centers, and the fact that NIP is now
available in private clinics. However, the immunization rates for the optional recommended
immunizations (which are not included in NIP) are low. Therefore, active policies to address
the low rate should be developed.
2. Factors Affecting the Immunization Rate

2.1. Background
The most important factors in immunization are to maintain higher immunization
rates than the optimum level, to administer immunizations at appropriate times (ages and
intervals), and to complete every necessary immunization for raising the publics immunity
(Santoli, et al., 2000; Hull, McIntyre, 2006). It is not easy to complete all immunizations
on time because of the numerous types of vaccinations and different complex schedules
of the core required immunization list. Furthermore, some immunization records might
be incomplete. Thus, to improve the immunization rate, groups that are at risk of missing
immunizations should be identified so that concrete strategies can be developed.
Socio-demographic characteristics, health care systems, factors affecting immunization
policies, and psychological variables are well-known factors related to immunizations.
Socio-demographic factors are pre-determined. Thus, risk groups could be identified based
on these factors; however, the strategies that have been developed targeting such groups are
limited. For accessibility to the health care system, public interest and relevant strategies
are crucial in eliminating obstacles. Hence for this, the NIP coverage project (the medical
expense reimbursement system) has been implemented since 2009. Psychological variables
including knowledge, attitudes, and beliefs about immunization could be improved by
education and campaigns. Therefore, considering socio-demographic characteristics and
psychological variables, immunization rates can be improved through a systematic and
detailed strategy (Gust, et al., 2005).
2.2. Survey Introduction

Since 2011, the Survey on Factors Affecting Immunization Rates has been performed
as part of the National Immunization Survey. In the 2011 survey, CATI asked parents and
guardians of three-year-old children to check the following information: parents ages,
parents education levels, parents employment, residential areas, parents existence, health
care security status (i.e. type of insurance held), birth weights, the total number of children,
main parent or guardian who brings children to clinics for immunizations, and obstacles to
immunization.
2.3. Survey Results

2.3.1. Parents Ages
With the group of fathers 45 years old and above used as a reference, the rates of completed
immunization were 2.62 times higher than the group of 30- to 34-year-old fathers, 2.07
times higher than the group of 29-year-old and younger fathers, 1.99 times higher than the
group of 35- to 39-year-old fathers, and 1.40 times higher than the group of 40- to 44-yearold fathers. In the case of mothers, the rate of completion was 1.95 times higher than the
group of 30- to 34-year-old mothers. These data were all statistically significant <Table
8-3>.
Table 8-3 | Relationship between Parents Ages and Rates of
Completed Immunization
Parent and age

Fathers age
p-value
Odds
ratio
95% confidence
interval
Lowest
Highest
6,381
0.000
0.94
0.93
0.96
127
0.024
2.07
1.10
3.89
29 years old and younger
30-34 years old
1,415
0.000
2.62
1.90
3.61
35-39 years old
2,915
0.000
1.99
1.49
2.65
40-44 years old
1,557
0.025
1.40
1.04
1.89
45 years old and older
1.00
Mothers age
367
6,921
0.000
0.97
0.96
0.99
551
0.254
1.44
0.77
2.70
29 years old and younger
30-34 years old
2,883
0.026
1.95
1.08
3.51
35-39 years old
2,730
0.189
1.48
0.82
2.66
40-44 years old
674
0.626
1.16
0.63
2.15
45 years old and older
83
1.00
Note: 1. D
ependent variable: completely vaccinated three-year-old children (0, standard) and completely
vaccinated three-year-old children (1)
2. The complete immunization of three-year-old children is defined as 13 total doses of NIP vaccinations
excluding JEV. In other words, four doses of DTaP, three doses of poliovirus, one dose of MMR, three
doses of hepatitis B, one dose of BCG, and one dose of varicella
2.3.2. Parents Education Level

The complete immunization rates were higher in highly educated parents. In other words,
the complete immunization rate of fathers who graduated from college or a higher level was
1.52 times higher than those who graduated from high school or a lower level. In addition,
it was 1.42 times higher for mothers who graduated from college or a higher level than
those who graduated from high school or less. All of these data were statistically significant
<Table 8-4>.
Table 8-4 | Relationship between Parents Education Level and Rate of
Completed Immunizations
Parent and education level

Fathers education level
N
6,293
p-value
Graduated from high

school or below
2,011
Graduated from
college or above
4,282
0.000
6,837
0.000
Graduated from high

school or below
2,624
Graduated from
college or above
4,213
95% confidence
interval
Lowest
Highest
1.00
1.52
1.30
1.79
1.00
1.42
1.22
1.65
0.000
Mothers education level
Odds ratio
0.000
2.3.3. Parents Employment

The rate of immunization completion was 1.86 times higher in the group of employed
fathers, and this difference was statistically significant <Table 8-5>.
Table 8-5 | Relationship between Parents Employment

and Rate of Completed Immunization
Parent and employment
status
Fathers employment status
Unemployed
Employed
Mothers employment status
p-value
6,421
0.000
146
6,275
0.004
6,968
0.000
Unemployed
4,491
Employed
2,477
0.093
Odds ratio
95% confidence interval

Lowest
Highest
1.00
1.86
1.22
2.83
1.00
0.88
0.75
1.02
2.3.4. Health Care Security Status

Compared to medical aid beneficiaries, the rate of completed immunization of those
with national health insurance was 1.35 times higher, and this difference was statistically
significant <Table 8-6>.
Table 8-6 | Relationship between Health Care Security Status and Rate of
Completed Immunization
Health care security status
Health care security status
National Health
Insurance
Medical Aid
p-value
7,040
0.000
6,601
0.035
439
Odds ratio

Lowest
Highest
1.35
1.02
1.77
1.00
Medical aid members: Those with a household income below a certain threshold qualify for subsidized coverage
of health insurance costs
2.3.5. Total Number of Children and Birth Order

The more children were in a family, the lower the rates of completed immunization.
(With one additional child, the completed immunization rate was 0.84 times lower.)
Furthermore, comparing the completed immunization rates between groups (three-yearold children) who were the fourth child or beyond and those who were an only child, the
completed immunization rate was 2.32 times higher in the only child group. In addition, it
was 3.12 times higher in the first child group and 1.97 times in the second child group. In
other words, the complete immunization rates were higher in the early birth order groups.
These differences were statistically significant <Table 8-7>.
Table 8-7 | Relationship among the Total Number of Children, Birth Order, and
Rate of Completed Immunization
Total number of children and
birth order
p-value
Odds
ratio
Total number of children
7,040
0.001
Birth order of three-year-old

children
7,040
0.000
Only child
1,314
The first child among

multiple children
The second child among

multiple children
95% Confidence interval

Lowest
Highest
0.84
0.76
0.93
0.003
2.32
1.34
4.03
2,198
0.000
3.12
1.81
5.37
2,716
0.013
1.97
1.16
3.37
The third child among

multiple children
730
0.293
1.35
0.78
2.35
The fourth or additional

child among multiple
children
82
1.00
2.3.6. Barriers to Immunization

The biggest barrier to immunization was forgetting the scheduled immunization dates.
The completed immunization rate in respondents noting this reason was 0.62 times lower
than those reporting no obstacles. The rate was 0.70 times lower in parents who responded
that they were too busy to visit a clinic for immunization. However, the rate of completed
immunization was 1.49 times higher in parents who responded that the cost of vaccination
was expensive. These differences were all statistically significant <Table 8-8>.
Table 8-8 | Relationship between Obstacles to Immunization and

Complete Immunization Rates
Types of barriers
p-value
Forgetting immunization dates
7,040
0.000
Not an obstacle
5,755
Is an obstacle
1,285
0.000
Too busy to visit a clinic
7,040
0.000
Not an obstacle
6,503
Is an obstacle
537
0.000
Too expensive
7,040
0.000
Not an obstacle
2,619
Is an obstacle
4,421
0.000
Concerned about side effects
7,040
0.000
Not an obstacle
6,665
Is an obstacle
375
0.136
Low quality of the public health

center
7,040
0.000
Not an obstacle
6,901
Is an obstacle
139
0.410
Accessibility to the public health

center (transportation)
7,040
0.000
Not an obstacle
6,991
Is an obstacle
49
0.781
Missing immunization dates

because children had been sick
during immunization periods
7,040
0.000
Not an obstacle
6,994
Is an obstacle
46
0.736
Odds
ratio

Lowest
Highest
1.00
0.62
0.52
0.74
1.00
0.70
0.54
0.89
1.00
1.49
1.29
1.73
1.00
1.32
0.92
1.89
1.00
0.81
0.50
1.33
1.00
1.14
0.45
2.88
1.00
0.86
0.36
2.04

Chapter 9
Directions for Future Development
Directions for Future Development
Immediately after Korea was liberated from Japan and established a government in 1948,
the Korean War occurred from 1951 through 1953. As a result, the public health system
could not meet its demand because the structure of the public health system, along with
the broader socioeconomic system, was completely destroyed by the war. From this point,
South Korea has developed its public health system over the past 60 years, culminating in
the modern system of today. The specific reasons for the success of the early immunization
program despite the insufficient public health infrastructure are as follows:
First of all, technical support from developed countries including the WHO was applied
efficiently. The Saemaeul (New Community) Movement (a pan-national campaign for
local community development beginning in the 1970s), environmental hygiene projects
initiated by the recommendation of WHO advisors, and family planning services including
childrens health care were important opportunities to enlighten residents at the village
level. Such opportunities were the foundation of the comprehensive immunization program
as these projects were implemented based on the growth of the national economy.
Secondly, public health branches and health workers were systematically distributed
throughout towns. Even though the national socioeconomic condition was terrible several
decades ago, strongly driven by a policy named the solution for a doctorless town, the
Korean government built public health branches in every town, which was a fundamental
administrative unit. In addition, health care providers in charge of family planning services,
maternal and child health care, and the tuberculosis control program were assigned to
control acute and chronic infectious diseases and to provide family planning services,
which were the most urgent needs. Providing public training and services by visiting each
village, collective education and practice were possible. In other words, the village was the
unit in which community-based participatory health programs were carried out.
Thirdly, mobile mass immunization was conducted by mobilizing resources on a grand

scale. Various infectious diseases such as dysentery, typhoid, cholera, Japanese encephalitis,
polio, and measles occurred year after year and the deaths caused by these diseases were
difficult to control given the insufficient infrastructure. In particular, people could rarely
access the public health clinics due to the shortage of clinics and limited transportation. In
these circumstances, having a legal imperative for a mobile mass immunization program,
for the distribution of access to physicians and for the mobilization of health care workers,
was an important and effective strategy.
Lastly, the government actively implemented the policy of the solution for a doctorless
town by distributing physicians to towns. To place physicians and nurses in public health
institutions, the government provided a scholarship covering tuition fees and additional
expenses for students in the health care professions. After graduation, they were expected
to work in areas assigned by the government. Afterward, the government continued to
distribute physicians in each town (the primary unit by law) and also used incentive systems.
Physicians had finally been placed in every town by 1983, and infectious diseases were
successfully controlled by public health worker education and infectious disease controls
in the 1960s and 70s.
As mentioned above, even right after the war, outstanding results were possible due to
the central and local governments efforts to distribute medical benefits to the basic unit, the
town, in a short period of time. However, this outcome only occurred in urgent situations
and could not be suggested as a future-oriented immunization plan. By the 2000s, successful
experiences of infectious disease control had accumulated, including hepatitis B perinatal
transmission prevention, measles eradication, and the rapid control of influenza A virus
subtype H1N1. As the socioeconomic level continues to improve, additional immunization
projects will be needed to control future infectious diseases with the proper immunization
programs. Concrete suggestions are as follows:
First of all, strategies for the eradication of infectious diseases that can be prevented
by vaccination need to be established. The immunization rate in South Korea is over 95%
because people are now having few children due to successful family planning with high
education-oriented parenting and massive interest in their children. Due to these conditions,
decisions should now be made on the priority of projects for eradicating infectious diseases
that can be prevented by vaccination.
Secondly, in light of data on the measles and H1N1 pandemics, existing and new
infectious diseases threaten the public with either a 10-year cycle or a 5- to 6-year cycle.
Thus, preparation must be made for these types of epidemics and crises. In addition, public
information and education strategies should always be ready.
Chapter 9. Directions for Future Development 155
Thirdly, trained immunization experts should be secured to study and control infectious
diseases. The ability to react to the outbreak of infectious diseases must be developed by
studying the ones that could threaten the public in the future. Sufficient knowledge and
experience should be accumulated to prepare for the influx of infectious diseases from
foreign countries. Furthermore, proper strategies for maintaining safety from foreign
infectious diseases need to be provided to protect Koreans overseas.
Fourthly, vaccine production capacity must be securely established. When a pandemic
breaks out, the supply of vaccines could be temporally limited. As a result, the public would
not be able to get vaccinated. Thus, uninterrupted investment and research are needed to
increase the quality of vaccine production. The capacity to generate a self-sufficient supply
is surely an important public health and safety issue.
Finally, even though South Korea has a high vaccination rate of over 95%, the participation
of vulnerable social groups in vaccination programs must be expanded, and more types of
vaccines should be covered by the government (i.e., be included in NIP). Recently, a large
number of foreign immigrants have settled in South Korea from many countries that have
different vaccination programs, which means different types of vaccines are provided by the
government and methods of vaccination are different. Thus, active vaccination strategies
for foreign immigrants are needed. In addition, it should be noted that parents still have
an economic burden because some vaccines have not been included in the core required
immunizations of the National Immunization Program.
In conclusion, even though South Korea has achieved a high immunization rate, has
succeeded in controlling and eradicating serious infectious diseases, and has established
an outstanding public health system in a short period of time, the work of predicting and
protecting Koreans from infectious diseases is not completed yet. Therefore, ongoing
investment and research will establish Korea as a country safe from infectious diseases.
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Centers for Disease Control and Prevention (2009), Guidelines for an Immunization
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Centers for Disease Control and Prevention (2011), National and State Vaccination
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Centers for Disease Control and Prevention (2012), Information on Immunization
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Chung, CW (2011), Study of Perinatal Hepatitis B Prevention Programs in South Korea,
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Gust, Brown, et al. (2005), Immunization Attitudes and Beliefs among Parents: Beyond a
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Hull, BP, and PB McIntyre (2006), Timeliness of Childhood Immunisation in Australia,
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Immunisation Advisory Centre (2010), Immunisation Coverage and Vaccine Preventable
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Ko, UY (2007), Project for Expanding Beneficiary Eligibility of the National Mandatory
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Korea Institute for Health and Social Affairs (2010), An Evaluation on the Management
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Lee, Jeon, et al. (2009), Evaluation of Data Error, Completeness, Timeliness of National
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Ministry of Health (2007), The National Childhood Immunization Coverage Survey
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Appendix
1. National Publications
1. Notification
2011 Standards and Methods for the Implementation of Immunization Notification
2. Guidelines
2006 Varicella Management Guideline
2011 Epidemiology and Management of Infectious Diseases Targeted for Immunization
2011 Management Guidelines on Infectious Diseases Targeted for Immunization
2011 Post-immunization Allergic Reaction Management Guideline
2012 Infectious Disease Management Project Guideline
2011 Epidemiology and Management of Infectious Diseases
2011 Infectious Disease Surveillance and Reporting Guideline
2012 Management Guidelines on Core Required Immunization Support Project of
Medical Institutions (used in public health centers)
2012 Guideline for the Project on Vaccination of School Children
2011-2012 Seasonal Influenza Management Guideline
2012 Hepatitis B Project Guideline (used in public health centers)
2009 H1N1 Immunization Project Guideline
3. Publications
2004 Measles White Paper
2006 5-year National Measles Elimination Project White Paper
2009-2010 H1N1 Countermeasure White Paper
2011 Disease Management White Paper (annual)
2011 Health and Welfare Statistical Yearbook (annual)
2011 Disease and Health Joint Management System White Paper
Sample Surveillance Newsletter on Infectious Diseases at Schools (weekly)
Sample Surveillance Newsletter on Infant Infectious Diseases (weekly)
Weekly Report on Health and Disease (weekly)

Infectious Disease Occurrence Weekly Bulletin (weekly)
Immunization Monthly Newsletter (monthly)
4. Educational Materials
2011 New Education for Immunization Managers Working for City, Provincial, and
Public Health Centers
2011-2012 Seasonal Influenza Education Material
2011 Standards on Professional Education Material and Safety Management of
Immunization
2011 Education on Core Required Immunization Support Project (Immunization
Expansion Project)
2011 Educational Material on Project to Prevent Perinatal Transmission of Hepatitis B
5. Internet Websites
Ministry of Health and Welfare (http://www.mw.go.kr)
Korea Centers for Disease Control and Prevention (http://www.cdc.go.kr)
Disease and Health Joint Management System (http://is.cdc.go.kr)
Immunization Helpdesk Website (http://nip.cdc.go.kr)
Infectious Disease Web-based Statistics System (http://stat.cdc.go.kr)
2. M
ain Content of Law on the Prevention and Management
of Infectious Diseases
The responsibility of the national and local governments (Article 4)
- Establishing preventive measures on infectious diseases
- Diagnosis, education, and PR on infectious diseases
- Nurturing professional human resources for infectious disease prevention
- Establishing and implementing the immunization plan for disease prevention
Appendix 161
Appendix
E
stablishment of committees such as the Infectious Disease Management Committee
(Article 9)
- Immunization Expert Committee
- Immunization Injury Compensation Expert Committee
- Tuberculosis Expert Committee
- Epidemiological Research Expert Committee
- Infectious Disease Crisis Countermeasure Expert Committee, etc.
Reporting of individuals, such as doctors (Article 11)
- When allergic reactions occur after immunization, one must immediately report to
the director of the public health center.
Routine immunizations (Article 24)
- Types: Diphtheria, Polio, Measles, Tetanus, Tuberculosis, Hepatitis B, Mumps,
Rubella, Varicella, Japanese encephalitis, and infectious diseases designated by the
Minister of Health and Welfare
- The person in charge of routine immunization: Mayor, head of the county, district
chairman (director of public health center)
- Immunization institution: Public health center and private medical institution
Record reporting
- Public health center: report to mayor, provincial governor, or the Minister of Health
and Welfare
- Private medical institution: report to mayor, head of the county, or district chairman
(president of public health center)
C
onfirmation of the completion of immunizations- Target institutions: elementary
schools, middle schools, kindergartens, daycare centers
- Person in charge: Mayor, head of the county, or district chairman (director of public
health center)
Planning and Producing Vaccines
- The president of the Korea Centers for Disease Control and Prevention can have the
necessary amount of immunization medication produced beforehand.
The Coverage of Immunization Costs

Nation
- Infectious disease education and PR costs
- Production costs for immunization medication and research costs
- Immunization-related injury compensation costs
- More than 1/2 of the expense of what every city and province covers
Metropolitan City and Province
- Immunization costs
- 2/3 of the expense of what every city, county, and district covers
City, County, and District
- Immunization costs
- A part of the expense on immunization from the commissioned medical institution
Appendix 163
P
ublic health care
facilities
Other facilities
Trained medical
personnel
Institutions
providing
immunizations
Immunization
providers
Same as on the left
Same as on the left
2. Japanese
2. Japanese
2. Japanese
encephalitis, typhoid,
2. Tuberculosis, fever
influenza, fever with
with renal syndrome
renal syndrome
renal syndrome,
renal syndrome
epidemic, influenza.
epidemic a total of
varicella a total of 5
epidemic - a total of
4 infectious diseases
infectious diseases
4 infectious diseases
Infectious
diseases
specified by
the Ministry
of Health and
Welfare
Same as on the left
Same as on the left
Same as on the left
Same as on the left
1. Typhoid fever,
diphtheria, pertussis,
tetanus, measles,
mumps, rubella,
polio, hepatitis
B, Japanese
encephalitis,
varicella
Laws and
regulations
applicable to
epidemics
1. Diphtheria,
polio, pertussis,
measles, tetanus,
tuberculosis,
hepatitis B, mumps,
rubella, varicella a
total of 10 infectious
diseases
1. Diphtheria,
polio, pertussis,
measles, tetanus,
tuberculosis,
hepatitis B, mumps,
and rubella a
diseases
2010 Revision
1. Diphtheria,
polio, pertussis,
measles, tetanus,
tuberculosis,
hepatitis B, mumps,
and rubella a
diseases
2006 Revision
2005 Revision
2002
Area
Same as on the left
Same as on the left
Same as on the left
Same as on the left
2011 Revision
3. The Main Contents of the Notice Regarding the Implementation, Criteria, and
Methods for Immunization
Appendix
Appendix 165
2005 Revision
Same as on the left
Same as on the left
2002
1. Recording
immunization
histories and issuing
coupons
2. Training and
publicity regarding
immunizations
3. Check if there are
any immunization
contraindications
Record and preserve

matters relating to the
immunization record, in
particular:
1. Vaccinee personal
information and immunization history
2. Physical examination
to determine
if anything
abnormal had been
detected after an
immunization in
the past, including
specific history of
allergy and other
local reactions
Obligations of
immunization
providers
Recording and
archiving
Area
Same as on the left
Same as on the left
2006 Revision
Record and preserve

materials related to the
immunization in the
immunization register
and the management
information system
1. The biographical
details of the person
immunized
2. Immunization
history, the order
immunizations were
given, vaccine used,
batch number, date
of immunization and
immunization methods
Same as on the left
2010 Revision
Record and preserve

the following
in the electronic
Immunization Registry
Information System
1. The biographical
details of the person
immunized
2. Immunization
history, the order
immunizations were
given, vaccine used,
batch number, date
of immunization and
immunization methods
Same as on the left
2011 Revision
Same as on the left Same as on the left Same as on the left Same as on the left
Vaccine
purchase and
storage
2011 Revision
Public health facilities should receive

the biological shipment certificate
and verify the manufacturing date, the
manufacturing company, the provider,
Same as on the left Same as on the left Same as on theleft Same as on the left
the product (lot) number, the validity
period, the quantity purchased, and the
quantity in stock. Transport and keep the
vaccines in proper containers.
2010 Revision
Reporting
obligations
2006 Revision
The medical institutions offering

immunizations should report to the
public health center about the methods
used for preventing infectious diseases.
If there is any serious adverse effect
after the immunization relating to the
vaccine, this should also be reported
directly to the public health center.
2005 Revision
Immunization
booklet
2002
Record the type of vaccine given, the

type of vaccine and the date of the
immunization that should be given next
in the immunization booklet brought
Same as on the left Same as on the left Same as on the left Same as on the left
by the guardian. Make a copy of the
immunization booklet in case it gets lost.
Ask the parent or guardian to record a
copy of the immunization record.
Area
Appendix
Appendix 167
4. Recommended Immunization Schedule for Children (in English)
79
-
Maternal death rate

(per 10,000 births)
National income per

capita (dollar)
Tuberculosis occurrence
rate
Cholera contraction rate
58.2
12.1
Crude death rate

(per 1,000 people)
Infant death rate

(per 1,000 born infants)
42.1
Crude birth rate

(per 1,000 people)
52.4
(M:51.1
F:53.7)
30.0
Natural population
increase rate
(per 1,000 people)
Average life span (age)
3.01
1960
Population growth rate

(per 1,000 people)
Index
8.0
31.2
23.2
2.21
1970
125
46.2
0.6
4.2
255
8.3
53.0
61.93
M:54.92
(M:58.67
F:60.99
F:65.57)
9.5
34.6
25.1
2.57
(65)
1966
3.3
607
5.6
38.0
63.82
(M:60.19
F:67.91)
7.7
24.8
17.1
1.70
1975
0.4
2.5
1,660
4.2
17.3
65.69
(M:61.78
F:70.04)
7.3
22.6
15.4
1.57
1980
2.2
2,355
3.4
13.3
68.44
(M:64.45
F:72.82)
5.9
16.1
10.2
0.99
1985
1.8
6,303
3.0
12.8
71.28
(M:67.29
F:75.51)
5.6
15.2
9.5
0.99
1990
0.1
68.2
11,735
2.0
7.7(96)
73.53
(M:69.57
F:77.41)
5.3
15.7
10.3
1.01
1995
5. The Index of Social Health in South Korea from 1960 to 2010
41.4
11,292
1.5
6.2(99)
76.02
(M:72.25
F:79.60)
5.2
13.3
8.2
0.84
2000
0.03
72.45
17,531
1.4
4.7
78.63
(M:75.14
F:81.89)
5.0
8.9
3.9
0.21
2005
0.02
72.40
20,562
1.24(08)
3.5(08)
80.79
(M:77.20
F:84.07)
5.1
9.4
4.3
0.26
2010
Appendix
Appendix 169
0.3
0.3
0.1
3.3
0.1
5.0
Paratyphoid contraction
rate
Smallpox contraction
rate
Typhus fever contraction

rate
Relapsing fever
contraction rate
Diphtheria contraction
rate
Epidemic cerebrospinal
meningitis contraction
rate
Epidemic encephalitis
contraction rate
Bacillary dysentery
contraction rate
Polio contraction rate
Pertussis contraction
rate
-
11.2
Typhoid contraction rate
Measles contraction rate
0.2
1960
Dysentery contraction
rate
Index
0.1
4.4
0.0
0.1
11.8
0.4
1966
2.5
11.2
11.8
0.5
1.8
0.1
13.1
1970
5.2
14.1
3.4
0.1
0.1
1.0
0.0
0.0
1.5
1975
2.3
13.1
4.1
0.0
0.2
0.1
0.0
0.0
0.5
1980
3.0
3.1
1.1
0.1
0.0
0.5
0.0
0.5
1985
4.9
8.0
0.4
0.3
0.0
0.5
1990
1.0
0.2
0.0
0.1
0.3
0.1
0.8
1995
6.2
68.0
0.1
5.1
0.1
0.1
0.0
0.5
2000
3.83
0.01
0.02
0.65
0.18
0.06
0.39
2005
12.15
0.23
0.05
0.45
0.21
0.11
0.27
2010
0.1
-
5.0
-
Mumps contraction rate
Malaria contraction rate
Meningococcal
meningitis contraction
rate
Epidemic hemorrhagic
fever contraction rate
contraction rate
Varicella contraction rate
12.2
0.1
1966
0.1
0.1
49.4
1970
0.3
0.0
0.9
1975
0.3
0.1
0.0
1980
0.1
0.0
1985
0.0
0.2
0.0
0.0
1990
0.6
0.2
0.0
0.2
1995
3.7
0.4
0.0
8.6
2000
3.97
13.93
0.01
0.01
2.81
2005
48.66
11.31
0.05
0.02
3.53
2010
* The unit of occurrence rate from 1960 to 1990 is per 100 people and per 100,000 people from 1995 to 2010
* The numbers indicate the number of reports from each city and province according to the Infectious Disease Prevention Act. The number of the population is based on the midyear population. Contraction rate=number of patients/total population x 100,000. The numbers after August 2000 include the number of doctor-patients due to the renewal of the
law on reporting standards
1960
Index
Appendix
www.ksp.go.kr
Ministry of Strategy and Finance, Republic of Korea
339-012, Sejong Government Complex, 477, Galmae-ro, Sejong Special Self-Governing City, Korea Tel. 82-44-215-2114
KDI School of Public Policy and Management
130-722, 85 Hoegiro Dongdaemun Gu, Seoul, Korea Tel. 82-2-3299-1114
www.kdischool.ac.kr
Knowledge Sharing Program

Development Research and Learning Network
130-722, 85 Hoegiro Dongdaemun Gu, Seoul, Korea
Tel. 82-2-3299-1071
www.kdischool.ac.kr
www.mosf.go.kr

23 Korean National Immunization Program For Children

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23 Korean National Immunization Program For Children

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2012 Modularization of Koreas Development Experience:

Korean National Immunization

2012 Modularization of Koreas Development Experience:

Korean National Immunization Program

2012 Modularization of Koreas Development Experience

Korean National Immunization Program

Korean National Immunization Program for Children

Ministry of Health and Welfare, Republic of Korea

Sok-Goo Lee, Chungnam National University School of

Advisory Hoan-Jong Lee, Seoul National University College of Medicine,

Ministry of Strategy and Finance (MOSF), Republic of Korea

Government Publications Registration Number 11-7003625-000039-01

Knowledge Sharing Program

2012 Modularization of Koreas Development Experience

Korean National Immunization

06 Korean National Immunization Program for Children

Contents | LIST OF CHAPTERS

08 Korean National Immunization Program for Children

4. Infectious Disease Surveillance System94

Contents | LIST OF CHAPTERS

010 Korean National Immunization Program for Children

Contents | LIST OF TABLES

012 Korean National Immunization Program for Children

Contents | LIST OF TABLES

014 Korean National Immunization Program for Children

Contents | LIST OF FIGURES

Contents | LIST OF FIGURES

016 Korean National Immunization Program for Children

Contents | LIST OF BOXES

018 Korean National Immunization Program for Children

Information System. Chapter 6 introduces Koreas internationally well-regarded hepatitis

020 Korean National Immunization Program for Children

2012 Modularization of Koreas Development Experience

1. History of Korean Immunization Program

1. History of Korean Immunization Program

022 Korean National Immunization Program for Children

Box 1-1 | Smallpox and Ji, SeokYeong

Chapter 1. Background 023

Table 1-1 | History of the Korean Immunization Program

Important background information

Establishment of clinic in the Jeonju

Enactment of inoculation regulations

Production of vaccination and

Diphtheria, tetanus, 8 other

1954 cough, typhoid fever, typhus,

Production of vaccination and

Inactivated vaccine used for immunization

1976 Cholera, tetanus

Routine immunizations introduced

WHO declared eradication of smallpox

1980 Measles, mumps, rubella (MMR)

MMR vaccine introduced

1983 Measles, polio

Introduction of routine immunizations

Changed the 85 temporary immunization

2000 Mumps, rubella

Introduction of routine immunizations

Implementation of an ambitious 5 year

2004 Diphtheria, tetanus

2005 Varicella (Chicken pox)

Introduction of routine immunizations

024 Korean National Immunization Program for Children

Important background information

Korean National Immunization Program for Children

Sok-Goo Lee, Chungnam National University School of

Advisory Hoan-Jong Lee, Seoul National University College of Medicine,

Put all the policies on infectious diseases together and